Therapeutic Communication Technique v3b4x

Therapeutic Techniques of Communication TYPES OF QUESTIONS Open Ended Questions: Begin with what, how, when, where, can you tell me. Inquiries in which the received can respond in whatever direction is most appropriate for him/her at the time. Encourages the most spontaneous answer. Ex: “How are you today?” Closed Ended Questions: Begin with “do,” “is,” “are,” will.” Responses are usually limited to “yes” or “no” or other one word response. Useful when wanting a short, direct answer. Avoid when trying to get client to expound on an issue. Ex: “Are you feeling better today? 1. Focusing Questions: Targets certain are on which the nurse wishes the client to provide more detail. (Text refers to this as a Directing Question). Ex: “Can you describe how you felt when you became so anxious?” 2. Validation: A question to that the listener has heard the sender accurately. (Arnold & Boggs refers to this as restating). Ex: Are you say…..” or “What I’m hearing you say is___________. Is that accurate?” 3. Clarification: A question that asks the client to expand or simplify a previously spoken message. Asks the client to be more specific or to say it in a different way to eliminate any confusion. Ex: “Can you explain…..,” “Can you help me understand………,” “How do you mean?” or “I’m not sure I understand.” 4. Reflecting: Restates a portion or all of what client has just said. Focuses on feelings of client. Used to emphasize a portion of client’s message, to express doubt in a questioning tone, or to continue on that topic. Caution: If overused, listener sounds like a parrot echoing everything client says. May seem disinterested or mechanical. Ex: You feel no one understands you.” 5. Paraphrasing: Similar to reflecting, but the nurse re-phrases client’s message in her own words focusing on the cognitive aspects. It invites client to continue with his/her thoughts. Ex: Client: “This wound isn’t getting any better, no matter what the doctor does.” Nurse: “You’re not noticing any improvement in spite of the various treatments.” 6. Sequencing: Places events in chronological order for listener understanding or to help client explore cause and effect relationships. Ex: “When did you first begin to feel your life had lost its meaning?” 7. General Leads: Short words or phrases to encourage the client to elaborate on the issue he/she is discussing. Ex: “uh-huh,” “I see,” “Yes,” “Go on.” May be nonverbal, nodding, facial expression, gesture. 8. Silence: A pause in which the listener provides the client to gather his thoughts and/or for the listener to observe non-verbal communication. The listener remains attentive, accepting, and expectant but without intruding into the client’s thoughts. Also useful in times of powerful emotion. It if becomes extended, re-open conversation with openended question. Ex: “What’s going on with you right now?”

Therapeutic Techniques of Communication (con’t) 9.

Summarizing: Used at the end of an interaction to review important issues of prior to transition to a new topic.

10. Verbalizing Implied Thoughts or Feelings: The nurse voices thoughts or feelings which the client may have alluded to or hinted at, but of which he/she may not be fully aware. Helps client clarify and process feelings and thoughts. Should always be validated. Ex: “From what you’ve said it sounds like you really felt betrayed. Is that how you felt?” 11. Acknowledging Feelings: A responding skill that communicates to clients that their feelings are understood and accepted. Provides safe, non-threatening environment so client feels secure in continuing to verbalize. Ex: “I can just imagine how frightened you must have been!” 12. Giving Information: Providing information that may be helpful to a client or which has been requested. Ex: Client: “I can’t wait to get home to watch football with a tall, cold beer.” Nurse: “I wonder if you’re aware that the mediation you’re taking shouldn’t be combined with alcohol.” 13. Seeking Information: When the nurse requests data from a client about feelings, events, attitudes, beliefs, symptoms, etc. Ex: “How are you feeling?” 14. Sharing Observations: Verbalizing an observation focused on the client’s physical and/or emotional state designed to increase the client’s self-understanding. Ex: “You seem upset.” 15. Voicing Doubt: In a tentative or questioning tone of voice, the nurse verbalizes concern about the veracity or accuracy of something the client has said. Ex: “It’s difficult for me to believe that just one beer made you drunk enough to out.” 16. Confrontation: In a caring, calm, respectful manner the nurse clarifies specifically the client’s incongruent thoughts, feelings, behaviors or unacceptable behaviors. Articulates why the behavior is a problem, requests a behavior change and encourages a change by matter-of-factly explaining the positive consequences of changing behavior and/or the negative consequence of not changing behaviors. It assists client’s selfawareness and enforces boundaries. Ex: “When you smoke in the presence of oxygen, I’m afraid an explosion will result and you’ll be injured. Please limit smoking to the designated smoking area. Otherwise, I’ll have to remove your cigarettes or call security.” 17. Touch: A powerful listening response which conveys empathy used to a client who is overwhelmed with deep emotion, pain, loneliness, sensory deprivation, confusion, fear or anxiety. It must be used judiciously and with observation of client’s response to the touch. Some client’s may be offended or misinterpret touch. Touch must be appropriate in location, frequency, and pressure. 18. Humor: Used Judiciously after rapport and trust have been developed in the nurseclient relationship, humor can help clients appreciate the absurdities and incongruities of life, defuse an intense situation, distract from painful feelings or physical pain.

Therapeutic Techniques of Communication (con’t) 19. Immediacy: Involves focusing on the current interaction of the nurse and the patient in the relationship. It is a significant dimension because the patient’s behavior and functioning in the relationship are indicative of functioning in other interpersonal relationships. Immediacy involves sensitivity to the patient’s feelings and a willingness to deal with these feelings rather than ignore them. As with the other dimensions, high-level immediacy responses should not be suddenly presented to the patient. The nurse must first know and understand the patient and have developed a good, open relationship. Ex: Patient: “The staff here couldn’t care less patients. They treat us like children instead of adults.” Nurse: “I’m wondering if you feel that I don’t care about you or perhaps I don’t value your opinion?” 20. Reframing: Help client to see things from a different perspective, providing an opportunity to modify their outlook, feelings or emotional state, thereby promoting client control and emphasizing client strengths. Examples are helping clients to find a positive aspect in a negative situation or finding meaning in a difficult situation. Ex: Client: “I never thought I’d have a heart attack; I’m so depressed.” Nurse: “Your wife said you always overwork yourself. Can you see anything positive about this crisis in your life?” 21. : Information given in an empathetic manner about the other’s behaviors, actions, attitudes, and ideas. It should be given with an “I” message describing the nurse’s reaction to the client, be specific versus general, clear, honest, with appropriate timing and it should enhance the goals of the relationship. 22. Setting Limits: Establishing boundaries for behaviors. Consequences of going beyond those limits are explained and enforced. Ex: “It is inappropriate to our relationship for you to speak to me in this manner. If it happens again I’ll not be able to provide nursing care for you.” 23. Boundaries: The definition and separation of the self from others by differentiating between behaviors which are and are not appropriate and acceptable. Ex: Client: I’d like to take you out to dinner after I’m discharged. Nurse: That’s a generous offer, but our relationship is strictly professional so I’ll have to decline.” 24. Redirecting: Distracting a client from undesirable behavior to re-focus on a healthier, more acceptable behavior. This is a time when it is appropriate and desirable to change the subject. Ex: Client in a nursing home and confused: “I have to go to work now.” Nurse gently leads client to dining area: “Tell me about your career while we have breakfast.” 25. Offering Self: Making self available to listen to the client. Ex: “Let’s sit over here and talk about what’s going on with you.” 26. Emotional Catharsis: Occurs when the client is encouraged to verbalize feelings, thoughts, behaviors, attitudes or beliefs that are troubling the client.

Therapeutic Techniques of Communication (con’t) 27. Coaching: Assisting a client verbally and/or non-verbally (pantomine desired action) to carry out tasks with which he/she is having difficulty. Often helpful with confused client. Ex: Client is having difficulty figuring out how to dress himself. Nurse: “Mr.____, first put on your underwear. Good. Now your T-shirt. O.K. Now your slacks, etc.” 28. Self-Disclosure: Honest personal statements about the self (nurse) intentionally revealed to a client when the nurse has experienced feelings, situations, or experiences to which are similar to those of the client. It is ONLY APPROPRIATE when it lets the client know he/she is understood, deepens trust in the nurse-client relationship, lets the client see the nurse as a normal human being, and augments an empathetic response. It should never be long, lack pertinence to the client’s situation, upstage or embarrass the client, or re-focus the interaction on the nurse. Ex: Nurse: “You’re really having a difficult time with this divorce. I can still how alone and scared I was when I divorced. Is that how you’re feeling?” 29. Confirming Responses: Responses that acknowledge the validity of client’s feelings and enhance self-esteem. Overlaps with other therapeutic techniques. 30. Disconfirming Responses: Any communication that discounts, contradicts, minimizes or denies the client’s feelings and lowers self-esteem. Includes many of the blocks to therapeutic communication. 31. Offering Alternatives: Helping the client consider and explore additional options. Ex: “Have you thought of….,” “Would it be useful to consider…..,” “Some people have found it helpful to…..,” “What else could you do?”

NON-THERAPEUTIC COMMUNICATION BLOCKS/ NON-THERAPEUTIC TECHNIQUES

EXAMPLES

EXPLANATION

1. Reassuring

I wouldn’t worry about… Everything will be all right. You’re coming along fine. You’re coming along fine.

..indicating that there is no cause for anxiety. Attempting to dispel the patient’s anxiety by implying there is no sufficient reason for it completely devaluates the patient’s own feelings. Hence, no values is placed in the patient’s judgment. Doing so communicates a lack of understanding and empathy to the patient. It makes the person giving it feel better for a short time but is meaningless to the patient. It tends to create negative feelings with the patient and blocking him from expressing further feelings. When commenting on a patient’s progress offer examples of concrete change rather than making meaningless statements as “You are doing fine.”

2. Rejecting

Let’s not discuss.. I don’t want to hear about…

..refusing to consider or showing contempt for the patient’s ideas or behavior. When a topic is rejected, it is closed off from exploration. When the patient is rejected or feels rejected therapeutic interaction ceases and he tends to avoid help so as not to risk further rejection. Insecure personnel are likely to fear the patient’s anxiety producing experiences and toward the patient’s expressions by giving premature reassurance for their own protection. Consequently, areas of the patient’s experiences are not submitted to investigation. Unless personnel know themselves and what behavior or ideas make them anxious new problems are likely to be added to those with which the patient is already struggling.

3. Disapproving

That’s bad. I’d rather you wouldn’t.

..denouncing the patient’s behavior or ideas. Disapproval implies the right to judgment on the patient’s thoughts and action and that the patient is expected to please the other person. It is important to acknowledge that the patient has the right to behave as he does, for a patient’s sick behavior is no more right or wrong, good, or bad, than a physical pain. Where a patient’s action may be harmful to others it is better to inform the patient of the effects of his actions than to offer value judgments.

4. Disagreeing

That’s wrong. I definitely disagree with… I don’t believe that.

..opposing the patient’s ideas. Disagreeing implies that the patient is wrong and places personnel in opposition to the patient. It makes the patient feel he has to defend himself and defending one’s ideas tends to strengthen them. Thus, ideas that may very well be delusional immature, et…may be reinforced. When personnel become judgmental they tend to see the patient as an object rather than a person and thus demonstrate less respect for the patient. Disagreement confines the patient while acceptance frees him to perceive new meanings and to grow emotionally.

5. Advising

I think you should Why don’t you.

..telling the patient what to do. Telling the patient what he should think or how he should behavior implies that the patient is incapable of self direction. It prevents the patient from struggling with thinking through his problems. It takes responsibility away from the patient and fosters his dependency upon judgment and guidance of others. Giving information differs from giving advise as it supplies the patient with additional data from which he can formulate judgment and action.

6. Probing

Now tell me about.. Tell me your history.

..persistent questioning of the patient. Probing tends to make the patient feel used and valued only for what he can give. It is included to put him on the defensive, causing to respond with anger, with distortions, or evasions, or not at all, promoting strained relationship. When the patient is quiet or withdrawn and unresponsive personnel tend to become increasingly anxious and more persistent in their questioning. Putting yourself in the patient’s place and focusing on his discomfort during the discussion tends to lesson this anxiousness.

7. Challenging

But how can you be president of the United States? If you’re dead, why your heart beating?

..demanding proof from the patient. Challenging puts the challenger in opposition to the patient. Delusional ideas serve a purpose for the patient and are not readily given up. They conceal feelings and meet needs that are real to the patient. Lessening the patient’s need for such ideas and perceptions can best be accomplished by discovering his unmet need and helping him to meet them in reality situations.

8. Testing

What day is this? Do you know what kind of hospital this is?

..appraising the patient’s degree of insight. Attempting to convince the patient of his degree of sickness and need for help meets the personnel’s needs, not the patient’s. It is often demanding that the patient have insight into his deficiencies. If the patient does not have some degree of insight of his incapacity, resting will cause him to become defensive. It is preferable to assume the best about the patient by phrasing inquiries. “Tell me what took place.” rather than, “Can you what happened?” The latter implies the patient is probably not capable of recall.

9. Defending

This hospital has a fire reputation. No one would lie to you. But Dr. B. is a very able Psychiatrist. I’m sure that he has your welfare in mind when he…

..attempting to protect someone or something from verbal attack. Defending what the patient has criticized is to imply that he has no right to express his impressions, opinions, or feelings. It does not change his feelings. They still need to be expressed. When personnel are defensive it is likely to create a negative reaction with the patient, causing him to withdraw or become hostile and very likely fortify the validity of his impressions. Defending ourselves or others alines outselves in opposition to the patient. If we are secure and have faith in the person or profession being criticized the need to defend should not be necessary.

10. Requesting an explanation

Why do you think that? Why do you feel this way? Why did you do that?

..asking the patient to provide reasons for thoughts, feelings, behavior and events. In requesting an explanation, the patient is usually asked “why” an event took place. A why question is intimidating: it asks for reasons which the patient does not know. He resorts to making up a reason. It is much more helpful for the patient to describe “what” has happened to “where” or “when”.

11. Indicating the existence of an external force

What makes you say that? Who told you that you were Jesus? What made you do that?

..attributing the source of thought, feelings, and behavior in others or outside influences. Questions as “what made you think that?” etc. imply that the patient was made or forced to think or act in a certain way by some other person or an external force. Also, such statements are ambiguous and encourage the patient to make use of projection as a means of alleviating anxiety. A better approach is to ask the patient “what happened- what events led you to draw such a conclusion.”

12. Belittling feelings expressed

Pt. I have nothing to live for..I wish I was dead. Staff. Everybody gets down in the dumps. OR I’ve felt that way sometimes.

..misjudging the degree of the patient’s discomfort. Equaling the feelings of the patient with that of “Everybody” or yourself implies the patient’s discomfort temporary, mild, and self-limiting. Thus responses as “smile, buck up, think of something nice, it could be worse, etc…” denotes a lack of empathy and understanding and offers no constructive assistance. When a patient is concerned with his own problems and misery he is not capable of concern about the misery of others. Therefore, any response that makes light of his problem or makes him feel small or insignificant add to his discomfort. Of greater value is recognition of the discomfort with responses as “You must be very uncomfortable” or “Would you like to talk about it?”

13. Making stereotyped comments

Nice weather we’re having. I’m fine, and how are you? It’s for your own good. Keep your chin up. Just listen to your doctor and take part in activities.. You’ll be home in no time.

..offering meaningless clinches, trite expressions. All impractical, meaningless comments should be avoided. Such empty conversation encourages a like response from the patient, often lacks sincerity, is frequently associated with a stereotyped attitude and thus little or nothing is communicated. A more positive approach is to focus on the patient’s problems or situation and give more reasonable and considered explanation in response to the patient’s queries..

14. Giving literal responses

Pt. I’m an Easter egg. Staff. What shade? OR You don’t look like one. Pt. They’re looking in my head with television. Staff. Try not to watch television. OR What channel?

..responding to a figurative comment as though it were a statement of fact. The patient often makes such figurative comments because it is the only way he has of putting into words the way it seems or feels to him. When personnel respond in kind it indicates their inability to understand when anxiety producing feelings are being described. Even though such statements have same literal meaning to the patient, personnel should not acquire a similar manner of thinking. A better approach is to focus on the feeling of the patient that are associated with the statement.

15. Using denial

Pt. I’m nothing. Staff. Of course you’re something. Everybody is something. Pt. I’m dead. Staff. Don’t be silly.

..refusing to it that a problem exists. Patients often deny their sickness or their problems. Personnel by their comments, tone of voice or facial expression should avoid using the same defense to keep from discussing problems that they think should not exist or an idea that they consider meaningless or even frightening. In effect, such action is closing the eyes and the mind to the patient’s problem. It keeps personnel from helping the patient identify and explore his difficulties. When such a technique is used by personnel it is most often used for their safety and comfort rather than an attempt to help the patient.

16. Interpreting

What you really mean is… Unconsciously you’re saying…

..seeking to make conscious that which is unconscious, telling the patient the meaning of his experience. Interpreting means to translate the manifestations into the language of consciousness. Nursing personnel respect the patient’s right to have his own feelings and to express them but they do not necessarily confront him with the intention of these feelings unless it is under counsel of the physician. Reasons why nursing personnel should not are: 1) it limits their usefulness in other roles; 2) the interpretations may be incorrect; 3) the patient may not be ready for it; 4) it keeps the patient from insights on his own; 5) interpretations like advice greatly exceed the need for them.

17. Introducing an unrelated topic

Pt. I’d like to die. Staff. Did you have visitors this weekend?

..changing the subject. When personnel change the subject or introduce one they direct the discussion. The initiative is taken from the patient. It is usually done by personnel to get to subjects they want to discuss. Personnel need to listen to the patient, wait for his communication, follow his leads, visualize themselves in the patient’s place, and take their cues from him instead of directing the communicative situation.

18. Giving approval

That’s good. I’m glad that you…

..sanctioning the patient’s ideas or behavior. Approval tends to limit the patient’s freedom to think or set in a way that displeases others. It leads the patient to strive for praise rather than progress. Approval and disapproval may alter undesirable behavior but usually it does not last for as soon as the motivating force is gone, the original behavior returns. Focusing on steps of learning for the patient allows for much greater effectiveness.

19. Agreeing

That’s right. I agree.

..indicating accord with patient. Agreement with the patient indicates that he is “right” rather than “wrong”. It gives the patient the impression he is “right” because his opinion is the same as the nurse. Opinions and conclusions should be exclusively the patient’s, not shared with the nurse. It limits the patient in modifying or changing his view later on. Personnel can best help the patient by making information available to him to evaluate and from his own opinions. Personnel can give acknowledgment where facts are concerned, as “that’s right.” when a patient asks, “this is Monday, isn’t it?” Agreeing should be distinguished from consensual validation. Agreeing indicates accord with the patient’s system of values, with his opinions, conclusions, or point of view. Consensual validation refers to shared understanding of the meaning of the words. No value judgment is involved.

DEFENSE MECHANISM First level: attempts at coping Suppression

Substitution Impact on Functioning: May help the person negotiate a difficulty for the short term, but because the material is stored in the unconscious, it is out of awareness & becomes an impediment to personal growth & development. Rationalization Impact on Functioning: When threat to the value of self is perceived, this mechanism helps the person maintain selfrespect, prevent feelings of guilt, explain behavior & provide socially acceptable motives for actions. If used pervasively & not recognized as an excuse, then it becomes a barrier to increasing self-awareness & personal development.

PURPOSE

DEFINITION

EXAMPLE

Helps keep forbidden drives & wishes out of one’s conscience.

Voluntary & intentional exclusion from conscious level of ideas, feelings, & situations that produce anxiety. Unwanted feelings are consciously kept out of awareness.

A student receives a poor report card & “forgets” to give it to his parents. Scarlet O’Hara’s, “I’ll think about that tomorrow.”

Helps reduce frustration by disguising motivations.

Replacement of an unacceptable need, attitude, or emotion with one that is more acceptable. The replacement of a highly valued, unacceptable object with a less valued one which is acceptable.

A woman feels unattractive physically, so she puts her energy into sports & competitive trials. A man wants to marry a woman but like his own mother.

Helps raise self-esteem & social approval by disguising motivations.

An attempt by the ego to make unacceptable feelings & behavior consciously tolerable & acceptable. Unacceptable feeling responses are justified or excused with logical reasons. “Sour Grapes”.

A nurse fail to do a procedure correctly & justifies her feeling of incompetence by stating that there is too much work on the ward. A girl cannot afford a dress she likes & says, “It made me look too fat anyway.”

DEFENSE MECHANISM Second Level: character development as ways of coping

PURPOSE

DEFINITION

EXAMPLE

Identification Impact on Functioning: Formulates identity. It is an attempt at wish fulfillment. The person aspires to the strength & desired qualities & traits of another. The person using this mechanism exhibits the desired traits. Use may promote G&D when ident. is positive – or dysfunction if the model is negative, self-destructive or antisocial.

Helps preserve the ego of the person while permitting disguise of inadequacies.

An attempt to fashion oneself to resemble an ired, idealized other. Unconscious assumption of similarity between oneself & another.

A little girl dresses like her mother & mimics her behavior. After hospitalization for minor surgery a girl decides to be a nurse.

Internalization or introjection

Attempts to deny or disguise through changing the ego in order to avoid threat to the self.

Taking within & symbolically incorporating loved or hatred wishes, values, & attitudes external to onself. Acceptance of another’s values & opinions as one’s own.

The child scolds his toys while playing, similar to the prohibitions of his mother. A woman who prefers a simple. life-style assumes the materialistic, prestige-oriented values of her husband.

DEFENSE MECHANISM Third Level: repressive attempts at coping

PURPOSE

DEFINITION

EXAMPLE

Compensation impact on Functioning: Protects the self from recognizing a personal limitations results in exaggerated responses that reflect a lack of self-awareness & selfacceptance & increase of dysfunctional behavior.

Helps relieve fears of failure in one activity by emphasizing another. Can result in characterological one-sidedness exaggerated responses that reflect a lack of self-awareness & self-acceptance & increase of dysfunctional behavior.

An attempt to make up for real or fancies deficiencies. A real or imagined inadequacy is alleviated from overcompensation by substituting another goal to maintain own self-respect & gain others approval.

A girl feels socially unattractive or inept, is responded to this way by peers, & becomes an honor student.

Sublimation Impact on Functioning: Effective in providing motivation for participation in vocational and recreational activities that enhance self.

Helps channel forbidden instinctual impulses into constructive activities.

Diversion of consciously unacceptable instinctual drives into personally & socially accepted areas. Redirecting libidinal drives (sexual & aggressive) into socially acceptable ones

Children make mud pies or finger painting instead of smearing feces. A person channels a sex drive into athletic activity, work, poetry, or music.

Displacement Impact on Functioning: An uncomfortable or distressing affect such as anger is generated in one situation, is ventilated in another unrelated situation toward an uninvolved person. The original source of the affect is never addressed or resolved, & problems are created where the inappropriate ventilation occurred.

Helps the person disguise feelings by using a less threatening object to release feelings.

Redirection of an emotional feeling from one idea, person, or object to another. Feelings are distorted, separated from the original object, and discharged toward a substitute object.

A physician berates a nurse, and, when a guest enters the patient’s room, the nurse harshly tells the person to wait for visiting hours. Father, embarrassed by his boss, comes home & ridicules his son in front of the son’s friends.

DEFENSE MECHANISM Projection Impact on Functioning: The disowning & attributing process enables people to remain blind to important aspects of their own personality & distort their perception of the other person. What is projected is an echo of their own unconscious. They cast the blame & shame onto another & deny their ownership to protect their self-image. This disowning interferes with their self-awareness & personal growth. Conversion

PURPOSE

DEFINITION

EXAMPLE

Helps the person avoid awareness of his own undesirable impulses.

Rejecting & imputing to others disowned aspects of the self; attributing intolerable wishes, emotional feelings, & motivations to other persons. Undesirable feelings are attributed to others.

A student suspects other classmates of being jealous of her good grades & thereby avoiding her. Archie Bunker calling his wife a “dingbat”.

Channels & contains unbearable feelings through body expressions.

Expression of intra-psychic conflict symbolically through physical symptoms. Feelings become unbearable & are rechanneled somatically.

A student develops headaches before taking an important test for which she feels unprepared. A man wants to beat a friend but can’t close his hand into a fist & his fingers will not curve.

DEFENSE MECHANISM Repression Impact on Functioning: The unconscious repressed thoughts continue to influence behavior. Repressed feelings may erupt at inappropriate times & interfere with functioning & relationships. Problems arise because of the unavailability of what is repressed for resolution through logical analysis & problem solving. The unawareness contributes to rigid & constricted perceptions, thinking, & behavior. A positive use occurs when a potentially overwhelming threat occurs & its use protects against overwhelming anxiety. Undoing Impact on Functioning: The failure to recognize the connection between current behavior & the past unacceptable. Action promotes unproductive & inappropriate behavior-a persistent obsessive thought pattern & compulsive ritualistic behavior result & interfere with current functioning.

PURPOSE Helps provide a forgetting & protective function for the ego.

Disguises & attempts to repair feelings or actions that have led to anxiety or guilt.

DEFINITION Involuntary & automatic regulation of unbearable ideas & impulses; submersion of these to unconscious realm. Unconsciously keeping unacceptable feelings out of awareness.

An attempt to actually or symbolically take away a previously consciously intolerable action or experience. Actions are regulated by other actions.

EXAMPLE After the recent death of a spouse, the remaining spouse cannot the marriage date. A man is jealous of a good friend’s success but is unaware of his feelings.

A mother who has just lost her temper & beat her children develops compulsive handwashing & child-checking behavior. A man proposes on a romantic night, does not again mention marriage & introduces the girl to his best friend.

DEFENSE MECHANISM Reaction Formation Impact on Functioning: To maintain the repression of an unacceptable impulse, the person denies or disguises a personality trait. This process may impair functioning if the motivation is out of awareness & estranged from the real self.

PURPOSE An undesirable impulse is kept out of awareness by emphasizing the opposite.

DEFINITION Acting oppositely to what the person really feels. Clues that reaction formation is occurring are an inappropriate intensity of feelings & the inability to consider alternative points of view.

EXAMPLE Desire to be sexually promiscuous may be concealed behind a moralistic demeanor. A recovering alcoholic ab controls the impulse to drink by becoming an activist in a program for preventing drunk driving. Overpoliteness, submissiveness, and excessive amiability are defenses against, and attempts to cover up feelings of hostility and aggression rather than resolve these feelings.

Helps the person get away from unpleasant reality.

Disowning of consciously intolerable ideas & impulses; refusal to perceive conflict. Painful or anxiety-producing aspects are blocked out.

A terminal cancer client appears not to be aware of approaching death. A mother has been told her child is below average intelligence; she still plans ahead for college because Uncle Joe was slow as a child too, and he’s a Ph.D.

Fourth level: regressive attempts of coping Denial Impact of Functioning: There is failure to recognize what is occurring in a situation or in one’s own participation in the situation interferes with effective functioning; failure to recognize what is happening generates behavior, complicates existing problems, & escalates a simple difficulty into a major crisis.

DEFENSE MECHANISM Dissociation Impact on Functioning: The use of this mechanism fragments the personality & interferes with the ability to function as an integrated person. The person experiences uned periods during which what is said or done occurs outside of awareness & is not recalled afterward. This mechanism is implicated in the development of dual or multiple personalities.

PURPOSE Helps the person put painful feelings aside & isolate & compartmentalize them.

DEFINITION Separation & detachment of emotional significance & affect from an idea or situation. Handling emotional conflicts, or internal or external stressors, by a temporary alteration of consciousness or identity.

EXAMPLE A client relates a tale of victimization on the street in a matter-of-fact manner, even joking at times. A woman has amnesia for the events surrounding a fatal automobile accident in which she was the speeding driver.

Regression Impact on Functioning: Interferes with the use of mature coping. Problems result from immature behavior, feeling & thinking.

Helps the person retreat from the present situation & become dependent & less anxious.

Retreat to an earlier & more comfortable level of adjustment.

A wife refuses to drive a car even though it causes the family much disorganization. Her refusal necessitates her husband taking her everywhere.