what is presentation in therapeutic communication

30 Top Therapeutic Communication Techniques in Nursing + How to Use Them

Nurses interact with people every day. Whether you talk with patients, family members, nurses, or other healthcare providers, it is vital for nurses to develop effective communication skills that promote favorable outcomes for patients and the healthcare team. Therapeutic communication should be at the core of every nurse-patient, nurse-caregiver, or interdisciplinary team relationship. Perhaps you are wondering, “What is therapeutic communication in nursing?” In this article, I will answer that question and provide you with examples of how to develop therapeutic communication skills. As you continue reading, you will find the 30 top therapeutic communication techniques in nursing + how to use them.

What Is Therapeutic Communication In Nursing?

What is the difference between therapeutic and non-therapeutic communication in nursing, when do nurses engage in therapeutic communication, 5 reasons why therapeutic communication is important in nursing, what are the five 5 essential components of therapeutic communication in nursing, 1. respect for the patient’s values and beliefs:, 3. patience:, 4. honesty:, 5. compassion:, 6 key skills required to successfully engage in nursing therapeutic communication, 1. verbal communication:, 2. nonverbal communication:, 3. written communication:, 4. patient education:, 5. make personal connections:, 6. learn to be culturally aware:, what are the top therapeutic communication techniques in nursing, technique #1: using active listening, why this technique works:, how to use this technique:, technique #2: seek clarification, technique #3: give broad openings and use open-ended sentences, technique #4: use time and/or sequence, technique #5: know when to be silent, technique #6 : give the patient recognition, technique #7: use observation skills, technique #8: encourage the patient to use comparisons, technique #9: focus, technique #10: summarize, technique #11: reflect, technique #12: use touch, technique #13: confronting, technique #14: be available, technique #15: offer hope, technique #16: find and share humor, technique #17: voice doubt, when appropriate, technique #18: encourage patients to describe their feelings, technique #19: suggest options (not medical advice), technique #20: use general leads, technique #21: offer acceptance, technique #22: exploration, technique #23: rephrase what the patient says, technique #24: verify impressions of what the patient says, technique #25: present reality, technique #26: share personal experiences, technique #27: asking patients to describe their perception of a situation/event, technique #28: attempt to translate what the patient says in the form of his feelings, technique #29: show empathy, technique #30: encourage participation in care planning, 15 non-therapeutic communication techniques nurses should avoid, 1. asking irrelevant personal questions:, 2. using stereotypical comments or cliches:, 3. giving unsolicited personal opinions:, 4. changing the subject:, 5. pressuring the patient:, 6. imposing the nurse’s approval or disapproval about a patient’s choice:, 7. arguing with the patient:, 8. using passive responses:, 9. giving aggressive or defensive responses:, 10. questioning the patient “why”:, 11. imposing sympathy:, 12. underloading:, 13. making the patient feel like what he is saying is not important:, 14. offering false reassurances:, 15. incongruence:, 7 most-common barriers to therapeutic communication in nursing and how to overcome them, barrier #1: physical barriers, about the barrier:, how to overcome:, barrier #2: language barriers, barrier #3: information overload, barrier #4: avoiding eye contact, barrier #5: talking too much, barrier #6: not being prepared, barrier #7: allowing personal conflicts to affect your outlook, bonus 5 expert tips to help nurses improve their therapeutic communication skills, 1. learn to use nonverbal signs to show you are listening:, 2. become a reader:, 3. learn to use your peripheral vision:, 4. be aware of how you demonstrate nonverbal communication:, 5. respect your patient's decisions:, my final thoughts, frequently asked questions answered by our expert, 1. what is the main goal of therapeutic communication in nursing, 2. is nursing therapeutic communication an intervention, 3. what is constructive criticism in nursing therapeutic communication, 4. is therapeutic communication necessary for all types of nurses, 5. which nurse would most likely be the best therapeutic communicator, 6. how do nursing schools teach therapeutic communication, 7. how does body language play a role in therapeutic communication in nursing, 8. how does therapeutic communication affect patient care, 9. how do nurses communicate therapeutically with alcoholic patients, 10. how to therapeutically communicate with pediatric patients, 11. is empathy a nursing therapeutic communication technique, 12. which communication technique is demonstrated when the nurse connects with a patient on a social level, 13. are there any disadvantages of therapeutic communication in nursing, 14. what happens when nursing therapeutic communication fails.

One of the main ways nurses establish trust with patients is through communication. Because nurses are likely to have the most direct contact with patients, effective nurse-patient communication is critical. Nurses can utilize proven therapeutic communication techniques that promote quality care.

What Is Therapeutic Communication?

Therapeutic communication is a collection of techniques that prioritize the physical, mental, and emotional well-being of patients . Nurses provide patients with support and information while maintaining a level of professional distance and objectivity. With therapeutic communication, nurses often use open-ended statements and questions, repeat information, or use silence to prompt patients to work through problems on their own.

Therapeutic Communication Techniques

There are a variety of therapeutic communication techniques nurses can incorporate into practice .

• Using Silence At times, it’s useful to not speak at all. Deliberate silence can give both nurses and patients an opportunity to think through and process what comes next in the conversation. It may give patients the time and space they need to broach a new topic. Nurses should always let patients break the silence.
• Accepting Sometimes it’s necessary to acknowledge what patients say and affirm that they’ve been heard. Acceptance isn’t necessarily the same thing as agreement; it can be enough to simply make eye contact and say “Yes, I understand.” Patients who feel their nurses are listening to them and taking them seriously are more likely to be receptive to care.
• Giving Recognition Recognition acknowledges a patient’s behavior and highlights it without giving an overt compliment. A compliment can sometimes be taken as condescending, especially when it concerns a routine task like making the bed. However, saying something like “I noticed you took all of your medications” draws attention to the action and encourages it without requiring a compliment.
• Offering Self Hospital stays can be lonely, stressful times; when nurses offer their time, it shows they value patients and that someone is willing to give them time and attention. Offering to stay for lunch, watch a TV show, or simply sit with patients for a while can help boost their mood.
• Giving Broad Openings Therapeutic communication is often most effective when patients direct the flow of conversation and decide what to talk about. To that end, giving patients a broad opening such as “What’s on your mind today?” or “What would you like to talk about?” can be a good way to allow patients an opportunity to discuss what’s on their mind.
• Active Listening By using nonverbal and verbal cues such as nodding and saying “I see,” nurses can encourage patients to continue talking. Active listening involves showing interest in what patients have to say, acknowledging that you’re listening and understanding, and engaging with them throughout the conversation. Nurses can offer general leads such as “What happened next?” to guide the conversation or propel it forward.
• Seeking Clarification Similar to active listening, asking patients for clarification when they say something confusing or ambiguous is important. Saying something like “I’m not sure I understand. Can you explain it to me?” helps nurses ensure they understand what’s actually being said and can help patients process their ideas more thoroughly.
• Placing the Event in Time or Sequence Asking questions about when certain events occurred in relation to other events can help patients (and nurses) get a clearer sense of the whole picture. It forces patients to think about the sequence of events and may prompt them to remember something they otherwise wouldn’t.
• Making Observations Observations about the appearance, demeanor, or behavior of patients can help draw attention to areas that might pose a problem for them. Observing that they look tired may prompt patients to explain why they haven’t been getting much sleep lately; making an observation that they haven’t been eating much may lead to the discovery of a new symptom.
• Encouraging Descriptions of Perception For patients experiencing sensory issues or hallucinations, it can be helpful to ask about them in an encouraging, non-judgmental way. Phrases like “What do you hear now?” or “What does that look like to you?” give patients a prompt to explain what they’re perceiving without casting their perceptions in a negative light.
• Encouraging Comparisons Often, patients can draw upon experience to deal with current problems. By encouraging them to make comparisons, nurses can help patients discover solutions to their problems.
•   Summarizing It’s frequently useful for nurses to summarize what patients have said after the fact. This demonstrates to patients that the nurse was listening and allows the nurse to document conversations. Ending a summary with a phrase like “Does that sound correct?” gives patients explicit permission to make corrections if they’re necessary.
• Reflecting Patients often ask nurses for advice about what they should do about particular problems or in specific situations. Nurses can ask patients what they think they should do, which encourages patients to be accountable for their own actions and helps them come up with solutions themselves.
• Focusing Sometimes during a conversation, patients mention something particularly important. When this happens, nurses can focus on their statement, prompting patients to discuss it further. Patients don’t always have an objective perspective on what is relevant to their case; as impartial observers, nurses can more easily pick out the topics to focus on.
• Confronting Nurses should only apply this technique after they have established trust. It can be vital to the care of patients to disagree with them, present them with reality, or challenge their assumptions. Confrontation, when used correctly, can help patients break destructive routines or understand the state of their situation.
• Voicing Doubt Voicing doubt can be a gentler way to call attention to the incorrect or delusional ideas and perceptions of patients. By expressing doubt, nurses can force patients to examine their assumptions.
• Offering Hope and Humor Because hospitals can be stressful places for patients, sharing hope that they can persevere through their current situation and lightening the mood with humor can help nurses establish rapport quickly. This technique can keep patients in a more positive state of mind.

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3.14: Therapeutic Communication Techniques

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• Maureen Nokuthula Sibiya
• Gümüşhane University via IntechOpen

Table 1 gives an overview of therapeutic communication techniques and provides examples of each technique [ 10 , 13 ].

-Therapeutic communication techniques.

Chapter 2 – Therapeutic Communication and Interviewing

Introduction: Therapeutic Communication

Therapeutic communication is at the foundation of the nurse-client relationship as reflected in Figure 2.1 . It is different than the conversations you have with friends, peers, family, and colleagues. Therapeutic communication has a specific purpose within the healthcare context. It is intended to develop an effective interpersonal nurse-client relationship that supports the client’s wellbeing and ensures holistic, client-centred, quality care.

Figure 2.1 : Therapeutic relationship.

The word “ therapeutic ” is related to the word therapy: it means having a restorative and healing effect on the mind and body as well as doing no harm. It is important to consider how you communicate and how this affects the client.

Points of Consideration

Learning Therapeutic Communication

Therapeutic communication is a learned activity that requires knowledge and continued practice and self-reflection.

In this chapter, you will first learn about nurses’ accountability related to therapeutic communication, and then you will learn about the principles, approaches, and strategies used in therapeutic communication in the context of a client interview.

Introduction to Communication in Nursing Copyright © 2020 by Edited by Jennifer Lapum; Oona St-Amant; Michelle Hughes; and Joy Garmaise-Yee is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Therapeutic Communication

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.

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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.

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Communication Skills in Counseling & Therapy: 17 Techniques

Such connections build on effective communication: what we express and how we express it (Wachtel, 2011).

Establishing empathy with clients requires a high degree of insight and a strong sense of shared understanding (Norcross, 2011).

Thankfully, communication is a skill that can be monitored and improved through awareness, education, and practice.

This article explores the importance of communication in therapy and counseling, introducing several vital skills and techniques and providing a set of worksheets to improve communication both inside and outside sessions.

Before you continue, we thought you might like to download our three Positive Communication Exercises (PDF) for free . These science-based tools will help you and those you work with build better social skills and better connect with others.

This Article Contains:

Communication in therapy and counseling, why is communication important in therapy, 5 skills of effective therapists and counselors, 17 communication techniques for your sessions, a look at nonverbal communication in counseling, 6 worksheets & activities for improving communication, resources from positivepsychology.com, a take-home message.

A task force set up by the American Psychological Association reviewed research on what makes therapeutic relationships most successful. Based on 16 meta-analyses, they found the following to be vital (Angelis, 2019):

• Agreeing therapy goals
• Getting client feedback
• Repairing ruptures (breakdowns in the therapeutic alliance)

With the therapeutic relationship as essential as the treatment method, communication and collaboration become increasingly valuable to the overall outcomes of therapy and counseling (Angelis, 2019).

Wachtel (2011, p. ix) highlights the importance of communication in the therapeutic technique and the need to “move from understanding the patient or client to putting that understanding into words.”

Communication may differ depending on the situation and the approach, yet it remains central to both talking cures and behavioral interventions. As a result, both seasoned professionals and those new to counseling or therapy will benefit from focusing on what they say and how they say it (Wachtel, 2011).

Framing effective therapeutic comments and achieving a fuller understanding of what is being said are skills that rely on awareness, good technique, and practice.

Communication can be subtle and multi-layered; an overt message often conveys a secondary meta-message. While we may not be conscious of the latter, it has considerable potential to affect therapeutic transformation – and failure. With that in mind, mental health professionals must care about what  they and the client say and how they say it (Wachtel, 2011).

They have the power to significantly impact the therapeutic alliance and outcome (Wachtel, 2011).

Our communications are more than simple interventions; they shape “the climate of the relationship and the tenor of the alliance” (Wachtel, 2011, p. 3). Even subtle changes in communication style and content can alter the client’s experience of the relationship, their progress, how they see themselves, and their potential for change.

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There are at least five essential communication skills for use in counseling and therapy, including the following (Nelson-Jones, 2005).

Verbal communication skills

Messages sent using words, such as “I understand. Please tell me more.”

Trained and empathic listening professionals should consider:

• Is the language too formal or informal?
• What are the content and focus of what is being said?
• How much is said? It is usual for the client to talk more than the professional.
• Who owns the speech? The pronoun “you” should be used carefully; it can suggest judgment.

Vocal communication skills

How we talk can signify what we are really thinking and how we truly feel.

Messages sent through the voice are influenced by the speaker’s:

• Articulation
• Speech rate

Each factor must be considered, tuned to the situation and subject, and modified to add variety to the conversation.

Bodily communication skills

Sometimes we forget to consider our whole body when we communicate, yet it can significantly affect communication, adding to or distracting from what we are saying.

Touch communication skills

When appropriate, a gentle touch to the arm or shoulder can communicate as much as and function alongside other communication skills.

However, physical contact risks over-familiarity or inappropriate interest and must be considered carefully.

Taking action communication skills

Communication is not always face-to-face. Reminders may be sent before a session or as a follow-up, including homework, such as further reading or exercises.

Communication boundaries are required to ensure that contact remains professional and through agreed methods.

The following communication techniques are equally helpful in therapy and counseling, improving overall communication.

Repairing ruptures

Many factors can lead to a breakdown in the alliance between the mental health professional and the client, including misunderstanding, mistrust, and disagreement on treatment goals (Angelis, 2019).

Good communication and related techniques can repair ruptures and lead to better outcomes (Saffran et al., 2011).

• Outline the therapeutic rationale at the beginning of the treatment and then reiterate it throughout.
• Respond to disagreements by modifying behavior to something more meaningful to the client; for example, use validation rather than challenge.
• Clarify misunderstandings early. When the client appears to withdraw, explore what is happening and acknowledge their feelings.
• Exploring the themes related to the rupture can help uncover more general problems, issues, and concerns.
• Link ruptures in the alliance to other areas of the client’s life. For example, concerns regarding lack of control during treatment may exist in other life domains.

Communication can successfully strengthen relationships in therapy and counseling by gathering feedback from the client and incorporating it into treatment. Taking note of feedback is likely to improve therapeutic outcomes and reduce client dropout (Angelis, 2019).

Several interventions can boost feedback in sessions and improve communication, including (Lambert & Shimokawa, 2011):

• Asking for and providing feedback on the therapeutic relationship
• Discussing shared experiences
• Increasing empathic engagement
• Offering more positive feedback
• Openly discussing readiness for change with the client
• Discussing the consequences of changing and not changing

When communicating with a client, displaying empathy strengthens the therapeutic alliance and promotes client openness (Elliott et al., 2011; Angelis, 2019).

As an essential element of emotional intelligence , empathy promotes change and is a vital aspect of therapy and counseling.

The ability and capacity to understand and share client feelings can be encouraged through several techniques, including (Elliott et al., 2011):

• Talking at a slower pace with periodic check-ins
• Actively listening to the client and reflecting back to them for their consideration
• Closely following the moving focus of the conversation as the therapy progresses
• Using empathic affirmation, such as, “Yes, it must be hard being pulled in all directions”
• Individualizing responses to clients so that they are relevant and personal
• Using evocative language to bring clients’ experiences alive

Empathic responses and the use of silence – Kelly Allison

“Nonverbal behavior exists in the interface between nature and culture” (Rimondini, 2011, p. 110). Its function in communication is to create meaning (Eaves & Leathers, 2018).

Nonverbal factors add to verbal communication by improving its accuracy and efficiency. Feelings and emotions are often more fully and accurately revealed nonverbally (Eaves & Leathers, 2018).

“When both speaking and listening, counselors, trainees, and clients disclose themselves through how they create their bodily communication” (Nelson-Jones, 2005, p. 22).

Nonverbal communication factors to consider include:

• Gaze – useful for coordinating speech and collecting feedback.
• Eye contact – crucial for showing interest and empathy.
• Facial expression – are we showing shock, disgust, or understanding?
• Posture – turning your body toward the speaker shows interest and engagement.
• Gestures – used to frame or illustrate what is being said or heard.
• Physical proximity – too close, and it can be awkward; too far, and a lack of connection may be felt.
• Clothes and personal grooming – appearing professional is vital, but so too is being able to connect, especially with a young person or group.

The following worksheets focus on multiple aspects of communication, enhancing awareness, and improving practical use.

Practicing verbal communication skills for therapists and counselors

Creating a safe environment for practicing communication skills is helpful for therapists and counselors new to the profession and the more experienced wishing to hone their skills.

Use the Practice Verbal Communication Skills worksheet in a group setting to practice verbal communication and reflect on skills you could improve.

Assess Vocal Communication Skills

Often, we are either unaware of our verbal skills or fail to reflect on them.

Use the Assess Vocal Communication Skills worksheet to both self-assess and receive feedback from others regarding key factors in vocal communication.

Consider what went well, not so well, and what you could do differently next time.

Active listening in therapy and counseling

We listen most effectively and form greater understanding when we actively listen to what is said.

Use the following questions in the Active Listening in Session worksheet to reflect on a recent session with a client and the vital factors of active listening.

• Did you use open-ended questions?
• Were you attentive?
• Did you seek clarification?
• Did you summarize what was said?
• Did you observe nonverbal as well as verbal communication?
• Did you use reflection (repeating back what you understood for confirmation)?
• Reflect on the answers you gave to each question and consider where you could improve or add additional focus in the future.

Being present for communicating in therapy and counseling

Awareness and being present are vital for effective communication in both counseling and therapy (Westland, 2015).

Use the prompts in the Being Present worksheet to increase awareness of what is happening inside your mind, body, and the environment.

• Describe your subjective awareness at that time. What physical sensations did you experience (e.g., tension, tingles, pressure)?
• Describe your outer awareness at that time. What did you sense in the environment (e.g., noises, smells, touches, tastes)?
• Describe your awareness of fantasy at that time. What mental processes took you out of the present moment into planning, explaining, and thinking?

Reflecting on each answer will help you increase understanding and awareness of your inner and outer world and improve your communication and understanding of the client.

Under- and over-involvement for communicating in therapy and counseling

Two kinds of reaction in therapy can significantly affect and even harm communication: under-involvement and over-involvement. “The under-involved psychotherapist is aloof, cool, and insufficiently responsive. The over-involved psychotherapist has lost touch with boundaries and become submerged in the client’s world” (Westland, 2015, p. 95).

Use the Under- and Over-Involvement in Communication worksheet to become more aware of what being too much and too little engaged with a client can be like.

Consider each of the following reactions:

• Neutral – remaining present without any particular type of reaction or engagement.
• Over-involved – over-engaging yourself with the client; feeling fully and emotionally involved in everything they have to say.
• Under-involved – disengaging yourself from what the client is sharing; physically and mentally distancing yourself from what the client shares; gazing out the window or thinking about a recent event.

Types of speech during communication in therapy and counseling

Depending on their personality, the treatment, and what is being discussed, the client may use one or more talking styles during a session (Westland, 2015).

Use the Types of Speech worksheet to become more aware during counseling by identifying and reflecting on the different styles used by the client and considering what they may mean.

Reflect on a recent session with a client and consider the following:

• Did the client talk at any point in a monotone – a single note?
• Did the client talk at any point on the horizontal, meaning their words were monotonous and seemed to fill the space?
• Did the client talk in an enticing and enthralling way?
• Did the client talk in a friendly yet circular way, never getting to the point ?
• Did the client talk like a runaway train ?

17 Exercises To Develop Positive Communication

17 Positive Communication Exercises [PDF] to develop help others develop communication skills for successful social interactions and positive, fulfilling relationships.

Created by Experts. 100% Science-based.

Good communication is essential to the process and outcome of therapy and counseling, and we have many resources that will help.

Why not download our Positive Psychology Coaching Manuals or our On Becoming a Therapist guide for a wealth of information regarding the skills, practices, and training that will help you excel in your career as a counselor or therapist?

Other free resources include:

• Nonverbal Mood-Spotting Game A fun activity for engaging children and adults in using and spotting nonverbal communication.
• Matching Nonverbal and Verbal Communication A set of questions to examine communication and attitudes during a recent engagement or session.
• Interpreting Body Language A practical worksheet for helping adults and children become more familiar with body language and its impact on communication.
• Body Communication Competence Using SOLER Use these helpful questions to reflect on your own and others’ body language using the SOLER acronym.

More extensive versions of the following tools are available with a subscription to the Positive Psychology Toolkit© , but they are described briefly below:

• Listening Without Trying to Solve

This valuable tool promotes listening without trying to problem-solve.

During this group exercise, participants pair up to explore two different scenarios:

• Sharing a problem while being listened to
• Sharing a problem while being offered advice and solutions

Taking turns, each member of the pair considers which listening approach is more beneficial.

• Mindful Versus Mindless Listening

Mindfulness encourages moment-to-moment awareness of the speaker’s message rather than becoming distracted.

Through teaming up with a partner, each person takes the role of both speaker and listener and adopts mindful and mindless listening.

The experience is evaluated with a series of questions, including:

What was it like being the storyteller/listener using mindful listening? What was it like being the storyteller/listener using mindless listening?

If you’re looking for more science-based ways to help others communicate better, check out this collection of 17 validated positive communication tools for practitioners. Use them to help others improve their communication skills and form deeper and more positive relationships.

While essential in all aspects of our lives, effective communication is particularly valuable in therapy and counseling, impacting the treatment alliance and outcome.

Direct, clear, and positive communication can help confirm treatment goals, encourage and provide feedback, and repair breakdowns to the overall process.

Reflecting on verbal and nonverbal communication can help us remove misunderstandings while clarifying the needs and meaning behind clients’ actions and identifying the changes they wish to make and the goals they want to set.

Whether you are new to the field or have years of experience, it is valuable to take time away from your busy schedule to consider what you say and how you say it . When treated as a craft, communication skills can be learned and improved through knowledge and practice to improve the client’s treatment experience.

Why not review the article and try out some of the communication worksheets? Reflect on where improvements can be made to your approach and style and how you can further enhance your skills to improve the therapeutic process and outcomes.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Communication Exercises (PDF) for free .

• Angelis, T. (2019). Better relationships with patients lead to better outcomes. Monitor on Psychology , 50 (10), 38.
• Eaves, M. H., & Leathers, D. G. (2018). Successful nonverbal communication: Principles and applications . Routledge
• Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. (2011). Empathy. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 132–152). Oxford University Press.
• Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 203–223). Oxford University Press.
• Nelson-Jones, R. (2005). Practical counselling and helping skills . Sage.
• Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients . Oxford University Press.
• Rimondini, M. (2011). Communication in cognitive behavioral therapy . Springer.
• Saffran, J. D., Muran, C., & Eubanks-Charter, C. (2011). Repairing alliance ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 224–238). Oxford University Press.
• Wachtel, P. L. (2011). Therapeutic communication: Knowing what to say when . Guilford Press.
• Westland, G. (2015). Verbal and non-verbal communication in psychotherapy . W.W. Norton & Company.

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Please when I download the free PDFs it is asking for payment. Could you please provide he free PDFs

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hello! im in middle school and im wondering what type of colleges would i have to attend in order to receive degrees for therapy?

Hi Ophelia,

You’ll find more information on what’s involved in becoming a therapist in our dedicated blog post . In general, you’ll need to complete a Bachelor’s degree in a related field (e.g., psychology), and then a Master’s degree in therapy or psychology. Lots of universities will have these programs if you search through their course guides online 🙂

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Therapeutic communication within the nurse-patient relationship: A concept analysis

Affiliations.

• 1 Department of Nursing and Healthcare Sciences, Munster Technological University, Ireland.
• 2 Munster Technological University, Changsha Central Hospital, Changsha, China.
• PMID: 33949044
• DOI: 10.1111/ijn.12938

Aims: To explore the concept of therapeutic communication within the nurse-patient relationship, using concept analysis.

Background: Therapeutic communication is a term that is often used in the nursing and related sciences literature, and yet it is still an ambiguous concept. Concept clarification is required to support other healthcare professionals' understanding and to guide theory development and practice.

Design: A concept analysis methodology was used, as proposed by Walker and Avant.

Data sources: A systematic literature search was performed using the Cochrane database, Science Direct, Health Source: Nursing/Academic Edition, Academic Search Complete, MEDLINE and PsycARTICLES with studies published within the last 20 years.

Review methods: The framework by Walker and Avant was adopted. The attributes, antecedents, consequences and uses of the concept were identified.

Results: The attributes were information exchange, mutual respect, engagement and managing health issues of concern to the patient. The antecedents were those related to the nurse and those related to the patient. The consequences included patient satisfaction, quicker recovery time, high-quality health care outcomes and positive nurse-patient relationship outcomes.

Conclusions: A theoretical definition of the concept was developed. The attributes, antecedents and consequences identified in this paper can be used in nursing education, research and managerial and organizational planning.

Keywords: concept analysis; nurse-patient relationship; nursing practice; therapeutic communication.

© 2021 John Wiley & Sons Australia, Ltd.

• Communication
• Education, Nursing*
• Nurse-Patient Relations*

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2.3 Communicating with Patients

Open Resources for Nursing (Open RN)

Therapeutic communication is a type of professional communication used by nurses with patients and defined as, “The purposeful, interpersonal information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.” [1] Therapeutic communication techniques used by nurses have roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients. [2] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.

Read an example of a nursing student effectively using therapeutic communication with patients in the following box.

An Example of Nursing Student Using Therapeutic Communication

Ms. Z. is a nursing student who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She does her best to solve their problems and answer their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her. [3] , [4]

Active Listening and Attending Behaviors

Listening is obviously an important part of communication. There are three main types of listening: competitive, passive, and active. Competitive listening happens when we are focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person and we assume we understand what the person is communicating correctly without verifying. During active listening , we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the main difference between passive listening and active listening. [5]

Touch is a powerful way to professionally communicate caring and empathy if done respectfully while being aware of the patient’s cultural beliefs. Nurses commonly use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can be very effective in providing comfort. See Figure 2.7 [6] for an image of a nurse using touch as a therapeutic technique when caring for a patient.

Therapeutic Techniques

Therapeutic communication techniques are specific methods used to provide patients with support and information while focusing on their concerns. Nurses assist patients to set goals and select strategies for their plan of care based on their needs, values, skills, and abilities. It is important to recognize the autonomy of the patient to make their own decisions, maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the patient, appropriate terminology should be used to promote patient understanding and rapport. When using therapeutic communication , nurses often ask open-ended statements and questions, repeat information, or use silence to prompt patients to work through problems on their own. [7] Table 2.3a describes a variety of therapeutic communication techniques. [8]

Table 2.3a Therapeutic Communication Techniques

In addition to the therapeutic techniques listed in Table 2.3a, nurses and nursing students should genuinely communicate with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to creating true connections with others. [9] Communicating with empathy has also been described as providing “unconditional positive regard.” Research has demonstrated that when health care teams communicate with empathy, there is improved patient healing, reduced symptoms of depression, and decreased medical errors. [10]

Nurses and nursing students must be aware of potential barriers to communication. In addition to considering common communication barriers discussed in the previous section, there are several nontherapeutic responses to avoid. These responses often block the patient’s communication of their feelings or ideas. See Table 2.3b for a description of nontherapeutic responses. [11]

Table 2.3b Nontherapeutic Responses

Strategies for Effective Communication

In addition to using therapeutic communication techniques, avoiding nontherapeutic responses, and overcoming common barriers to communication, there are additional strategies for promoting effective communication when providing patient-centered care. Specific questions to ask patients are as follows:

• What concerns do you have about your plan of care?
• What questions do you have about your medications?
• Did I answer your question(s) clearly or is there additional information you would like? [12]

Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-care experience, and provide high-quality care. Other suggestions for effective communication with hospitalized patients include the following:

• Round with the providers and read progress notes from other health care team members to ensure you have the most up-to-date information about the patient’s treatment plan and progress. This information helps you to provide safe patient care as changes occur and also to accurately answer the patient’s questions.
• Review information periodically with the patient to improve understanding.
• Use patient communication boards in their room to set goals and communicate important reminders with the patient, family members, and other health care team members. This strategy can reduce call light usage for questions related to diet and activity orders and also gives patients and families the feeling that they always know the current plan of care. However, keep patient confidentiality in mind regarding information to publicly share on the board that visitors may see.
• Provide printed information on medical procedures, conditions, and medications. It helps patients and family members to have multiple ways to provide information. [13]

Adapting Your Communication

When communicating with patients and family members, take note of your audience and adapt your message based on their characteristics such as age, developmental level, cognitive abilities, and any communication disorders. For patients with language differences, it is vital to provide trained medical interpreters when important information is communicated.

Adapting communication according to the patient’s age and developmental level includes the following strategies:

• When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures.
• When communicating with adolescents, give freedom to make choices within established limits.
• When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly. For example, if a patient has glasses and/or hearing aids, be sure these devices are in place before communicating. See the following box for evidence-based strategies for communication with patients who have impaired hearing and vision. [14]

Strategies for Communicating with Patients with Impaired Hearing and Vision

Impaired Hearing

• Gain the patient’s attention before speaking (e.g., through touch)
• Minimize background noise
• Position yourself  2-3 feet away from the patient
• Facilitate lip-reading by facing the patient directly in a well-lit environment
• Use gestures, when necessary
• Listen attentively, allowing the patient adequate time to process communication and respond
• Refrain from shouting at the patient
• Ask the patient to suggest strategies for improved communication (e.g., speaking toward better ear and moving to well-lit area)
• Face the patient directly, establish eye contact, and avoid turning away mid sentence
• Simplify language (i.e., do not use slang but do use short, simple sentences), as appropriate
• Note and document the patient’s preferred method of communication (e.g., verbal, written, lip-reading, or American Sign Language) in plan of care
• Assist the patient in acquiring a hearing aid or assistive listening device
• Refer to the primary care provider or specialist for evaluation, treatment, and hearing rehabilitation [15]

Impaired Vision

• Identify yourself when entering the patient’s space
• Ensure the patient’s eyeglasses or contact lenses have current prescription, are cleaned, and stored properly when not in use
• Provide adequate room lighting
• Minimize glare (i.e., offer sunglasses or draw window covering)
• Provide educational materials in large print
• Apply labels to frequently used items (i.e., mark medication bottles using high-contrasting colors)
• Read pertinent information to the patient
• Provide magnifying devices
• Provide referral for supportive services (e.g., social, occupational, and psychological) [16]

Patients with communication disorders require additional strategies to ensure effective communication. For example, aphasia is a communication disorder that results from damage to portions of the brain that are responsible for language. Aphasia usually occurs suddenly, often following a stroke or head injury, and impairs the  patient’s expression and understanding of language. Global aphasia is caused by injuries to multiple language-processing areas of the brain, including those known as Wernicke’s and Broca’s areas. These brain areas are particularly important for understanding spoken language, accessing vocabulary, using grammar, and producing words and sentences. Individuals with global aphasia may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences. [17]

The most common type of aphasia is Broca's aphasia . People with Broca’s aphasia often understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For example, they may intend to say, “I would like to go to the bathroom,” but instead the words, “Bathroom, Go,” are expressed. They are often aware of their difficulties and can become easily frustrated.  See the hyperlink in the box below for evidence-based strategies to enhance communication with a person with impaired speech. [18]

Strategies to Improve Communication with Patients with Impaired Speech

• Modify the environment to minimize excess noise and decrease emotional distress
• Phrase questions so the patient can answer using a simple “Yes” or “No,” being aware that patients with expressive aphasia may provide automatic responses that are incorrect
• Monitor the patient for frustration, anger, depression, or other responses to impaired speech capabilities
• Provide alternative methods of speech communication (e.g., writing tablet, flash cards, eye blinking, communication board with pictures and letters, hand signals or gestures, and computer)
• Adjust your communication style to meet the needs of the patient (e.g., stand in front of the patient while speaking, listen attentively, present one idea or thought at a time, speak slowly but avoid shouting, use written communication, or solicit family’s assistance in understanding the patient’s speech)
• Ensure the call light is within reach and central call light system is marked to indicate the patient has difficulty with speech
• Repeat what the patient said to ensure accuracy
• Instruct the patient to speak slowly
• Collaborate with the family and a speech therapist to develop a plan for effective communication [19]

Maintaining Patient Confidentiality

When communicating with patients, their friends, their family members, and other members of the health care team, it is vital for the nurse to maintain patient confidentiality. The Health Insurance Portability and Accountability Act (HIPAA)  provides standards for ensuring privacy of patient information that are enforceable by law. Nurses must always be aware of where and with whom they share patient information. For example, information related to patient care should not be discussed in public areas, paper charts must be kept in secure areas, computers must be logged off when walked away from, and patient information should only be shared with those directly involved in patient care. For more information about patient confidentiality, see the “ Legal Considerations & Ethics ” section in the “Scope of Practice” chapter.

Read more information about the Health Insurance Portability and Accountability Act of 1996 (HIPAA) .

• Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9 (8), 4968–4977. https://doi.org/10.19082/4968 ↵
• Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4 (2), e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/ . ↵
• “ beautiful african nurse taking care of senior patient in wheelchair ” by agilemktg1 is in the Public Domain ↵
• This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0 ↵
• Flickr - Official U.S. Navy Imagery - A nurse examines a newborn baby..jpg ” by MC2 John O'Neill Herrera/ U.S. Navy is in the Public Domain ↵
• American Nurse. (n.d.). Therapeutic communication techniques . https://www.myamericannurse.com/therapeutic-communication-techniques/ ↵
• Balchan, M. (2016). The Magic of Genuine Communication. http://michaelbalchan.com/communication/ ↵
• Morrison, E. (2019). Empathetic Communication in Healthcare. https://www.cibhs.org/sites/main/files/file-attachments/empathic_communication_in_healthcare_workbook.pdf?1594162691 ↵
• Burke, A. (2021). Therapeutic Communication: NCLEX-RN. https://www.registerednursing.org/nclex/therapeutic-communication/   ↵
• Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse . https://www.myamericannurse.com/strategies-for-effective-patient-communication/ ↵
• Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse. https://www.myamericannurse.com/strategies-for-effective-patient-communication/ ↵
• Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC) . Elsevier, pp. 115-116 ↵
• Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018 ). Nursing interventions classification (NIC) . Elsevier, pp. 115-116 ↵
• National Institute on Deafness and Other Communication Disorders (NIDCD). (2017, March 6). Aphasia. https://www.nidcd.nih.gov/health/aphasia ↵
• Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC) . Elsevier, pp. 115-116. ↵
• Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier, pp. 115-116. ↵

Process by which we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker.

Techniques that encourage patients to explore feelings, problem solve, and cope with responses to medical conditions and life events.

The purposeful, interpersonal information transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.

Responses to patients that block communication, expression of emotion, or problem solving.

A communication disorder that results from damage to portions of the brain that are responsible for language.

A type of aphasia that results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. They may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences.

A type of aphasia where patients understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. People with Broca's aphasia typically understand the speech of others fairly well. Because of this, they are often aware of their difficulties and can become easily frustrated.

Standards for ensuring privacy of patient information that are enforceable by law.

Nursing Fundamentals Copyright © by Open Resources for Nursing (Open RN) is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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THERAPEUTIC COMMUNICATION

This module aligns with key elements of APNA’s “Communication Theory and Interpersonal Skills” (American Psychiatric Nurses Association Education Council, Undergraduate Branch, 2022).

Module Outline

• Therapeutic Communication
• Non-Therapeutic Communication

Module Learning Outcomes

• Summarize therapeutic communication techniques
• Summarize non-therapeutic communication techniques

This module will review therapeutic communication techniques for non-therapeutic communication techniques. Nurses use therapeutic communication and empathy to cultivate rapport and a therapeutic relationship with patients. Below is an overview of therapeutic versus non-therapeutic communication strategies.

See Sharma and Gupta (2022) for further reading.

Therapeutic Communication Strategies

Sharma and Gupta (2022) summarize therapeutic communication strategies . These include:

• Open-ended questions -ask open ended questions to learn more about the patient and enable a free-flow of information exchange; closed-ended questions can be used to focus on specific information
• Active listening -active listening involves behaviors such as making eye contact and nodding
• Non-verbal indicators -be mindful of non-verbal indicators such as looking frequently at the clock/watch, toe-tapping, having an open body stance
• Silence -sitting with a patient during a difficult time and listening without interruption can be therapeutic
• Reflecting -the nurse repeats the patient’s communication back to them; encourages the patient to reflect on their feelings

Non-Therapeutic Communication Strategies

Summarization of Sharma and Gupta’s (2022) non-therapeutic communication include:

• Value judgments/Approval/Disapproval -avoid interjecting one’s biases and judgments, providing approval or disapproval of the patient’s thoughts or actions
• Negative body language -avoid crossing arms, appearing distracting, and standing over the patient during engagement/conversation
• Advice- avoid providing patient advice on recommended action(s)
• False reassurance- avoid false reassurance; can lead to mistrust, especially in the case that an expected outcome is not realized

Level Up RN. (2022). Nurse/client relationship, therapeutic communication-psychiatric mental health nursing [Video]. YouTube. https://youtube.com/watch?v=t_59thyrje8&si=EnSIkaIECMiOmarE

Key Takeaways and Learning Activity

You should have learned the following in this section:.

• The use of therapeutic communication techniques and empathy helps the nurse build rapport and a therapeutic relationship with the patient
• Non-therapeutic communication actions can erode a therapeutic relationship

Virtual Case Scenario

Empathy is putting yourself into the patient's shoes to allow the nurse's understanding of the situation from the patient's point of view.

MENTAL HEALTH IS A VERB Second Edition Copyright © 2023 by Jake Bush and Jill Van Der Like is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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• Open access
• Published: 29 April 2024

A qualitative study of the barriers to commissioning social and therapeutic horticulture in mental health care

• Carly J. Wood 1 ,
• Georgina Morton 1 ,
• Kathryn Rossiter 2 ,
• Becs Baumber 2 &
• Rachel E. Bragg 1 , 3  

BMC Public Health volume  24 , Article number:  1197 ( 2024 ) Cite this article

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Social and Therapeutic Horticulture (STH) is a process where trained practitioners work with plants and people to improve an individual’s physical and psychological health, communication and thinking skills. Evidence suggests that STH can support individuals with mental ill-health, however, current commissioning of STH within mental health care is limited. This study aimed to understand the barriers to commissioning STH in mental health care and to identify potential solutions to barriers, to support more widespread availability of services. 

Individuals with a role in mental health care commissioning from across the UK were invited to take part in semi-structured interviews via zoom. Interviews explored factors influencing the mental health services they commission or refer to, their perception of the role of STH in mental health care and the barriers to commissioning STH, together with potential solutions to any barriers identified.

Commissioners identified a lack of knowledge of STH and evidence of its effectiveness, and a culture which prioritises traditional medical models, as barriers to commissioning. Challenges for STH providers in responding to large-scale commissioning requirements were also highlighted as a barrier.

Conclusions

To upscale commissioning of STH in mental health care, STH interventions need to be embedded within NHS priorities and information on STH services and their effectiveness needs to be easily accessible to practitioners. The sector should also be supported in working collaboratively to enable commissioning of services at scale.

Peer Review reports

Mental health is defined as “a state of well-being in which every individual realises their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” [ 1 ]. Mental illness or mental ill-health is characterized by a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour, that is associated with distress or impairment in important areas of functioning, such as work, daily activities, or personal relationships [ 2 ]. The NHS identify five mental health levels which capture both mental health and mental illness on a continuum [ 3 ], moving from Level 0, where a person can take their own decision to independently improve their mental health and wellbeing, through to level 4, a person who is experiencing acute mental health crisis or who has a long-term serious mental illness. It is expected that people move through the different mental health levels either on a recovery pathway, or during times when mental health worsens and an increased level of intervention is required.

Common treatment approaches for mental health levels 2 and above include medication and psychological therapies [ 4 ]. However, medications such as anti-depressants may only provide significant positive effects for severe depression (level 4) [ 5 ] and have side effects or withdrawal symptoms [ 6 ]. Recent clinical trials also indicate that the efficacy of psychological therapies such as cognitive behavioral therapy (CBT) has diminished [ 7 ] whilst long waiting lists [ 4 ], can leave individuals without treatment for significant periods of time.

Social and Therapeutic Horticulture (STH), a process where trained practitioners work with plants and people to improve an individual’s physical and psychological health, communication and thinking skills [ 8 ], is one type of nature-based intervention (NBI) that is used to support individuals with mental ill-health. Although often used as an umbrella term for all gardening activities that target health and wellbeing, STH represents more targeted gardening activities that support individuals at mental health levels 2 and 3, typically provided by the voluntary, community and social enterprise (VCSE) sector. More specialised provision (termed ‘horticultural therapy’) for level 4 mental health needs where patients are typically in hospital or in-patient settings, and less specialised social gardening for level 1 needs is also available.

To date, multiple systematic reviews and meta-analyses have been conducted on the benefits of gardening and STH activities, reporting reductions in symptoms of depression and anxiety, reduced stress and mood disturbances, and improved quality of life, life satisfaction and community belonging for a range of groups, including the general public, patients with a range of physical illnesses, those with poor mental health, symptoms or diagnoses of mental illness [ 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. In a recent review of randomised controlled trials (RCTs), Briggs, Morris, and Rees [ 16 ] revealed an overall positive effect of STH interventions for depression and wellbeing, with half of the included studies involving individuals with a diagnosis or symptoms of mental illness. Despite the positive findings from this review, much of the existing evidence of the benefits of STH is focused on gardening and gardening activities for individuals at mental health level 0 and 1. There are fewer published scientific studies specifically focusing on individuals at mental health levels 2–4 who would need to be referred to STH interventions. Furthermore, most published studies use pre-post design methodologies without control groups, and incorporate a variety of outcome measures, thus making it difficult to combine findings across studies.

Despite evidence of the benefits of STH for a range of populations, and an increased interest from the Government and NHS [ 17 ] in the health and wellbeing benefits of engaging with nature, referrals to STH are not widespread from the NHS or within social prescribing schemes [ 18 ]. Current commissioning of NBI such as STH are primarily from the local authority, social services, self-referrals, special education, and Community Mental Health Teams [ 18 , 19 ], rather than routinely from general practitioners (GPs) or other clinicians. The NHS commissioning cycle involves a continual process of (i) strategic planning (to identify needs, review provisions and decide priorities); (ii) procurement of services and (iii) monitoring and evaluation [ 20 ]. Given that the NBIs have been highlighted as a key priority for improving mental health [ 17 ], wider commissioning might be expected. However, Shaw et al. [ 21 ] highlighted that commissioning for long term conditions is labour intensive for commissioners, with the scale and intensity of the work often not being proportionate to the service gains. It was also reported that commissioners were less comfortable with the transactional elements of their role, such as decommissioning services or seeking new providers [ 21 ]. These factors might act as barriers to commissioning of STH for mental health.

There has recently been a fundamental shift in the way that the health and care system is organized in the UK. In July 2022, Integrated Care Systems (ICS) were given statutory status, with Integrated Care Boards (ICBs) being set up to take on the NHS planning functions previously held by clinical commissioning groups, enabling joined up working and partnerships between health and social care and VCSE organisations [ 22 , 23 ]. It was hoped that this shift might result in increased commissioning of services based in VCSE sector, however, there also may be unique and unknown challenges experienced within this new structure. The aims of this study were therefore to (i) understand the barriers to commissioning STH in mental health care and (ii) identify potential solutions to these barriers to support more widespread availability of services.

To understand barriers to commissioning STH in mental health care, a combined deductive and inductive qualitative approach was used [ 24 ]. Semi-structured interviews, a common qualitative method, were conducted to obtain in-depth information about the experiences and perspectives of individuals with a role in mental health care commissioning. The interviews were conducted by a research assistant trained in qualitative data collection techniques and analysis.

Study context

Potential participants were identified by the research team and members of the Therapeutic Horticulture Stakeholder Group (THSG), a group established by Natural England in March 2022 with support from The National Academy of Social Prescribing (NASP), to explore how to grow the Therapeutic Horticulture offer and to support the scaling up of Green Social Prescribing (GSP) [ 25 ]. The group (currently chaired and convened by Thrive with support from Natural England) brings together leading organisations and professionals in this field with representation from Natural England, The National Academy of Social Prescribing (NASP), NHS England, academics, health care professionals, and organisations who support the provision of STH. With permission, THSG members provided the research team with the email addresses for individuals with a role in mental health care commissioning who might be interested in taking part in the research.

Recruitment

Individuals were purposively selected for participation in the research based on their job role to ensure representation across mental health ‘commissioning’ roles, including individuals who refer individual patients to mental health services through to those in senior positions with responsibility for commissioning regional mental health services. Participants were also selected to incorporate the perspectives of individuals both with and without experience of commissioning or referring to STH interventions and from across multiple regions of the UK. All potential participants were contacted via email by a member of the research team and provided with information about the study via a participant information sheet. Potential participants also shared information about the research with their colleagues who were also invited to take part in the study. A combined purposive and snowballing sampling approach was therefore used, two sampling techniques that are commonly combined [ 26 ]. In total 22 participants were invited to participate in the study.

Prior to participation in the research, participants were sent the definition of STH [ 8 ] and the mental health levels [ 3 ] to aid discussion of the role of STH in mental health care and to ensure consistency in their understanding of both STH and the NHS mental health levels. All participants provided informed consent prior to participation in the study and reconfirmed their consent at the start of the interview. Ethical approval was granted by Ethics Sub-committee 2 at the University of Essex (ETH2223-0519). Regulations regarding data management and storage were adhered to throughout the research.

Characteristics of participants

Nine participants provided consent to take part in an online semi-structured interview via zoom, including five males and four females. Participants were from a range of roles related to mental health care, with some participants referring individual service users to local services and others commissioning services for an entire region. Participants were a link worker, a GP, a consultant psychiatrist, a clinical psychologist, a commissioner of mental health services for children and young people, a community mental health team project manager, director of adult mental health, head of commissioning and policy, and a mental health programme lead. Most participants ( n  = 5) reported having a general awareness of GSP and NBI but no expertise in STH, whilst the remaining participants ( n  = 4) reported extensively researching STH and commissioning or supporting STH-type services. Participants were from multiple regions across the UK (with two participants spanning two regions), including Essex ( n  = 4), Suffolk ( n  = 1), Lancashire ( n  = 1), South Cumbria ( n  = 2), Somerset ( n  = 1), Kent ( n  = 1) and Manchester ( n  = 1).

Semi-structured interviews were conducted between February-April 2023. Interviews were conducted electronically in a private space at the participants and researcher’s place of work or in their homes. Interviews lasted between 17 min and 47 min, with this variation in duration resulting from the mixed experiences of STH amongst participants. Interviews were recorded using Zoom software and automated transcripts downloaded, checked, and corrected by the research assistant prior to analysis. All participants were asked about their job role, the factors that influence the mental health services they commission or refer to, their perception of the role of STH and the barriers to commissioning STH, together with potential solutions to any barriers identified. The topic guide used in the interviews is included in Appendix 1 . This guide was developed by the authors, in line with the study aims, with feedback provided by the THSG to refine the final interview guide.

Data were managed and coded using NVivo software version 12 (QSR International Pty Ltd., Doncaster, Australia, 2018). Transcripts were coded using reflexive thematic analysis, following the phases of Braun and Clarke [ 27 , 28 ]. Initially, two interview transcripts were coded independently by two authors (CJW, GM) and following discussion, a coding framework was developed and used to code the remaining transcripts. The coding framework was revised as coding continued. Themes were actively produced through exploration of the data and codes, and subsequent discussions between the wider research team.

As data analysis progressed and themes developed, the researchers discussed their own assumptions of the codes and themes. The researcher with the least experience in the mental health benefits of STH carried out the primary analysis to ensure that there was the least bias in the coding of the data. In the final stage of the analysis, four overarching themes were identified, each of which are described in detail below and include funding and workforce (theme 1), commissioning culture (theme 2), knowledge of STH (theme 3) and evidence of effectiveness (theme 4). Within these themes both the barriers to commissioning STH in mental health care (aim 1) and potential solutions to the barriers raised (aim 2) are discussed.

Theme one: funding and workforce

A lack of funding available for mental healthcare in the NHS was referred to as a key challenge for commissioning by most participants. Participants referred to a reduction in investment in mental health services over the last decade and reflected that a consequence of the reduced investment was that the NHS was “ trying to do more with less ”. Commissioning decisions were therefore suggested as being based around what can be delivered given the finances available and ensuring that commissioned services are “ cost effective ”. Commissioners were reported as being left in a position where they must commission based on what they can afford to provide rather than based on what they perceive to be best for their population.

In relation to STH specifically, most participants reported that the limited budgets available for mental health care result in sustainable and longer-term funding being a persistent problem for VCSE organisations. This was thought to result in the short-lived nature of STH services and high staff turnover. The lack of consistency in the offer across regions was also thought to compound this problem. Participants commented on the need to commission services that can cater for the entire population for which they commission, with “ pockets of services” making it difficult to do so. These “ pockets of services ” were deemed as not always being in areas where they were most needed, being less cost-effective, not being accessible for all and potentially requiring transportation to reach, which may pose financial issues for both individuals and organisations.

“They don’t want to be having just one project in one corner of their patch. They want to be able to say we’re doing this across the whole county.” (General Practitioner)

It was suggested that partnership working within the VCSE sector would enable a more consistent offer and a larger “ footprint” across regions, which would support access to larger funding streams, the growth of smaller VCSE organisations and subsequently wider scale commissioning of services.

Similar to a shortage of funding, most participants referred to a lack of workforce and resources within mental health services. One participant referred to a “revolving door of personnel” , resulting in continued staff shortages, whilst another referred to the constant juggling of resources. These issues were suggested to be a barrier to commissioning of new services such as STH.

“...new idea is...something they've not got time for as they’re so bogged down, it’s just kind of surviving day to day really. It’s almost too much to start thinking about something new, like a new nature-based therapy group.” (Clinical Psychologist)

One participant reported that the loss (and lack of replacement) of staff in particular roles essential to furthering the NHS Trusts green plans and working with the VCSE sector, further limited commissioning of STH. It was felt that embedding sustainability roles into Trusts would save money and that having directors and ‘champions’ who have a personal interest in sustainability, would help to influence commissioning boards and push the sustainability and STH agenda forward. However, the association between sustainability roles and commissioning of STH was only made by one participant, making it unclear to what extent these are reliant upon each other.

It was also reflected by one participant that the underfunding and understaffing issues within the NHS might present a key opportunity for the VCSE sector to assist in providing mental health care if it is given the chance, with another participant referring to the “missed opportunity” within their Trust to use small pots of funding to support the VCSE sector.

Theme two: commissioning culture

Several participants suggested that commissioned mental health services are driven by national requirements set out by the NHS and in the long-term plan [ 29 ] and that services such as STH are “not really embedded in national must dos…” Rather than facilitating a holistic approach to commissioning, the NHS guidelines (combined with the underfunding and under-resourcing of mental health care) were thought to limit the capacity of commissioners to allocate funding for services within the VCSE sector. Participants emphasised the need to see “ green initiatives ”, “ efforts ” and “ schemes ” within these national plans to support the commissioning of STH.

The commissioning culture of a “focus on reactive treatments rather than prevention” , was also reflected as a barrier to commissioning STH, with several participants discussing prevention of mental illness in relation to STH. Traditional approaches and therapies (i.e., talking/cognitive and drug therapies) were suggested as being prioritised, with a need to shift towards more preventative and holistic treatment in order for services like STH to be fully embedded.

“I think what we’re trying to do is stop the knee-jerk reaction to ‘we have to plug a gap over here’ and thinking about it more creatively and that’s what we’re trying to do. But it’s a big shift for the system, and it’s really easy to just keep throwing money at something that is a traditional approach to fixing something”. (Commissioner of mental health services for Children and Young People)

Some participants also suggested that STH should be embedded at every level of mental health care, allowing patients at all levels of mental health need to be referred to VCSE sector services and via a number of different referral pathways.

“It’s obvious, you build it in at all levels of referral...before GP, at GP, at IAPT [Increasing Access to Psychological Therapies], at secondary care. You just open the doors, and it would be successful. Reduce the demand on the NHS” (Consultant Psychiatrist).

It was felt that this approach would support individuals in accessing STH services, but that in order for it to be embedded at every level there would need to be “buy-in” from commissioners.

Theme three: knowledge of STH

Whilst all participants felt that there was a role for STH in mental health care, a lack of knowledge of STH by individuals with roles in referrals and commissioning was reported as a barrier to commissioning. While some participants within the study demonstrated or reported good knowledge of what STH is, the services available, and the range of mental and physical health benefits it could provide, this was cited as not being the case for all individuals within their organisations, where there was a mixture of different levels of knowledge. Some study participants also reported (or demonstrated) that they personally had limited knowledge of what STH is, who it is for and/or the evidence base surrounding the health benefits. There were some perceptions that STH would only appeal to certain groups and that it could only play a role in mental ill-health prevention or maintenance rather than in treatment, which contradicts the evidence supporting the use of STH in health care.

“This type of activity probably appeals to people in a particular demographic...I'm not necessarily convinced that people in their twenties and thirties would think of that as a go-to for leisure, pleasure, or seeing that as something that would benefit them..”. (Head of Commissioning and Policy)

The limited knowledge of STH was largely attributed to a lack of available information from providers of STH about the benefits of their services, who they are targeting, and how risk is managed. Most participants reported not receiving information or it not being readily available or easily accessible amongst the large volume of information that commissioners already receive. Some participants also referenced the need for the VCSE sector to promote or ‘champion’ their services and directly approach the NHS to highlight what they were doing within the community and to identify how this might align with ongoing NHS agendas.

“We need to be able to understand what the offer is, and it’s not always clear what community assets are available, and so I think the sector could do a better job for sure of collating those offers. But we need to understand what it is, what the needs are, what the value is, and how we can support it in a financially challenged environment.” (Community Mental Health Team Project Manager)

Overall, participants felt that greater and more effective sharing of information on STH and communication with commissioners was needed for STH to be commissioned more widely.

“Why are we not doing it? We don’t really know what they’re doing”. (Link Worker)

This was felt to be particularly important given that commissioners do not typically get training in STH.

Theme four: evidence of effectiveness

Evidence was highlighted as a factor influencing commissioning by all participants involved in the study, but to varying degrees and in varying contexts, perhaps reflecting differences in the knowledge of participants. Evidence of the effectiveness of STH was perceived by several participants as lacking in quantity and quality, with some reference to the need for high quality studies. Some participants also referred to a lack of awareness of evidence of the benefits of STH, in line with a lack of knowledge of STH broadly (Theme 3). However, one participant with extensive experience of STH, said that lack of evidence in relation to the benefits of STH was not the issue but rather a lack of evidence of how STH can “ structurally work within government commissioned services ”, alluding to potential difficulties in embedding services such as STH throughout the healthcare system.

Some participants also referred to the differences in evidence between levels of mental health need and how it was not necessarily effective for all mental health conditions, with one participant stating that it is not a “universal panacea” . One participant referred to the evidence of STH for severe and enduring mental illness and that whilst there was evidence to support its use, it was not widely publicised. Participants felt that evidence of the benefits of STH needed to be shared widely, easy to access and regularly updated.

“..the longer you work as a doctor, the less you become an academic because you become a clinician, so it’s less easy to access all that information. So, it’s a bit difficult to kind of prove to people that there is some decent evidence.” (Consultant Psychiatrist)

Several participants also referred to key performance indicators that the NHS are measured against and the need for STH services to have measurable outcomes that align with these indicators, for example the Warwick Edinburgh Mental Wellbeing Scale. A number of participants also commented that these outcomes should be focused on the effect STH has had on the individual patient, instead of statistics like waiting, access and discharge rates, which do not identify whether the patients’ condition has improved. However, there were also contradictory points highlighting that commissioning decisions were typically based around referral and discharge rates, the longer-term impacts on the healthcare system, and cost savings for the NHS, with these statistics being easier to examine than the impacts on patients.

As a result of challenges over measurement of outcomes and impact, some participants suggested changes to the ways that STH providers collect and provide evidence. Participants recommended that the sector focuses on providing qualitative evidence such as “ case studies ”, “ vignettes ” or “ user experience voices ” that tell “ the positive story ” of the impact their service has for the individual.

“...Health has a high bar for reporting, and we need to be able to prove that something has had an impact.. We can’t do the same thing really, with some of the green investments that we make. And so, I think we need to understand how we can evidence the impact it’s had, and it doesn’t always need to be data driven ...There are number-driven discussions, or data driven discussions. What is missing in that room is the patient’s story and the impact. And I think that’s where the third sector could really help us bring this to life.” (Community Mental Health Team Project Manager)

However, this type of evidence was acknowledged as being difficult to accomplish and often limited by the infrastructure of the organisations who may not have the capacity to collect this information. One participant suggested that if this evidence was available, the use of a video to demonstrate the impact on patients might be a technique that would “sell” the service to commissioners.

The aims of this study were to (i) understand the barriers to commissioning STH in mental health care and (ii) identify potential solutions to these barriers to support more widespread commissioning of STH services. The key themes that were produced from the data were issues around funding and workforce which prevented widespread commissioning of STH, a commissioning culture which makes it difficult to commission ‘non-traditional’ treatments, a lack of knowledge of what STH is and how it can be used, the services available, and a lack of [awareness of] evidence to support its effectiveness. There were a number of suggestions as to how these barriers could be overcome, most of which are likely to require systems-level change by both the NHS and VCSE sector.

In relation to funding and workforce, the continued reductions in funding for mental health care were identified as a key barrier to commissioning STH. This finding is mirrored in the recent evaluation of the Government’s GSP pilot, which identified unstable short-term funding and lack of system level support for the sector as a barrier to embedding GSP within statutory systems [ 22 ]. Furthermore, the recently established, ICBs, which were designed to support greater partnership working with the VCSE sector, have been asked to make a further 30% reduction in their running costs [ 30 ]. As a result, funding and resources for mental health services are likely to become even more stretched, further restricting commissioning of new services.

In the UK most NBIs, including STH, sit within the VCSE sector and are typically delivered by small-scale providers, allowing for a more bespoke, person-centred service [ 22 , 31 ]. However, this approach makes it difficult for STH providers to respond to large-scale commissioning requirements and combined with the funding and resources issue, is likely to result in commissioners continuing to consider STH as a less viable option for mental health care. Thus, it is essential that STH providers work in partnership to demonstrate the ‘offer’ for services they can provide on a regional scale [ 32 , 33 ]. This collaborative approach could be supported and facilitated through the use of regional nature-based VCSE networks such as the Norfolk Green Care Network [ 34 ] and the Reading Green Wellbeing Network [ 35 ]. These networks can promote partnership working between providers, become potential commissioning hubs and could enable providers to work together to apply for larger funding opportunities. Voluntary networks such as these could also help ICBs proactively engage with VCSEs but would need investment and support at the system-wide level to ensure sustainability.

Commissioning culture within the health service was also identified as a key barrier to commissioning of STH. Despite a commitment to increase use of personalised care, social prescribing, and community centred approaches for health and wellbeing across multiple Government and health organisations [ 36 , 37 ], the NHS long plan [ 29 ], which outlines the key priorities from 2019 to 2024, does not embed the use of these approaches as priorities. Instead, it prioritises helping people to get easier access to therapy for common mental disorders such as anxiety and depression; despite evidence to suggest diminishing effectiveness over time and poor outcomes for some groups [ 7 ]. Without community-based approaches being embedded within national plans, participants felt they had limited capacity to commission the VCSE sector.

The recently published NHS major conditions strategy case for change and strategic framework [ 38 ] calls for a focus on integrated working with community-based partners as part of the future long term conditions strategy, and a commitment to accelerating research to understand how mental, physical, and social conditions interlink and how they can be treated. Given that services such as STH can target mental, physical, and social needs simultaneously [ 39 ], it is possible that this focus may result in increased use of holistic services such as STH. However, until the full long-term conditions strategy is released, it is unclear how these approaches will be embedded and prioritised. As highlighted by participants, for interventions such as STH to be successful, they need to be embedded at every level of mental health care, allowing multiple entry points into the VCSE sector. The trend for prioritisation of traditional approaches to mental health care, as also reported by Shanahan et al. [ 40 ] and Tambayah et al. [ 41 ], alongside the suggested reluctance of commissioners in decommissioning services and seeking new providers [ 21 ], also needs to be overcome to promote greater variability in treatment options.

Lack of knowledge and awareness of STH, in a variety of contexts, was highlighted as a key barrier to service commissioning. There were some perceptions that STH would not appeal to all individuals or that it was not suitable for particular groups, for example younger people. A lack of knowledge about what STH interventions entail and the level of mental health need they can be appropriate for, was also highlighted by participants, with some interviewees referring to STH as solely a preventative health measure as opposed to a treatment option for acute and chronic mental illness. Furthermore, a lack of knowledge and awareness of what STH provision is available was identified as a barrier to commissioning. Lack of knowledge of local services has also been identified as a barrier to commissioning NBIs via GSP [ 22 ] and for commissioning STH by clinicians [ 42 ]. As commissioning of new services requires significant partnership working between both commissioners and service providers [ 21 ], this lack of awareness of what STH services are available locally is likely to be problematic.

Shanahan et al. [ 40 ] and Fixsen and Barrett [ 43 ] highlighted that referral and commissioning of NBI is influenced by the knowledge and interest of the GP, termed “GP buy-in” . Thus, individuals may not be offered interventions such as STH unless their health care provider has a particular interest in, knowledge of, or belief in its value. This need for ‘practitioner buy-in ’ is not aligned with traditional approaches where treatments are prescribed as ‘normal practice’ regardless of whether the practitioner has a particular interest in the approach. Providing a means by which practitioners can easily access information about STH services, such as regional or national directories of STH services, which enable identification of interventions across the UK and detail what they involve and who they are for, may facilitate increased awareness, knowledge and ‘ buy- in’ of STH interventions. However, any directory would need to be fully embedded in healthcare treatment, referral, and commissioning systems.

An interesting observation that emerged from the data was also the tendency of participants to refer to STH as green “schemes” , “therapies” or “initiatives” , indicating a perception that all nature-based activities are equivalent as reported by Sempik, Hine and Wilcox [ 44 ]. This is problematic and is likely to compound issues around what types of STH services are appropriate for different levels of need. To address this barrier, a framework for aligning STH provision with the NHS’ five mental health levels has been produced, identifying what types of activities, support, evaluation, and quality assurance are needed at each level, along with examples of beneficiaries across the UK [ 45 ]. To support partnership working, increased understanding and commissioning of STH, this framework should be adopted widely by both the health care sector and STH organisations and utilised in the suggested service directory.

Evidence of the effectiveness of STH was mentioned by all study participants as a factor that influences commissioning. Whilst some referred to a lack of awareness and publicisation of the evidence, as echoed in Tambayah et al. [ 41 ], others reported a lack in quality and quantity, or a lack of evidence for specific mental health levels or conditions. For individuals at mental health levels 0 and 1, there are a range of systematic reviews and meta-analyses demonstrating the benefits of gardening activities [ 11 , 12 , 14 , 15 ]. There are also numerous studies and reviews reporting the benefits for STH for individuals with symptoms of mental illness or diagnosed mental illness, aligning with mental health levels 2–4. However, in many cases this data is combined with data from individuals without mental ill-health, or for a range of mental health disorders [ 13 , 16 , 46 ], making it more difficult to isolate the evidence for specific conditions and those who require mental health intervention. Whilst studies focused on individuals at levels 2–4 with mild to severe mental illness have demonstrated positive effects for depression, wellbeing, quality of life and activities of daily living [ 16 , 47 ], many studies fail to incorporate comparison groups or randomisation procedures. To further enhance the evidence base, well-designed, high quality RCTs are therefore needed, along with sufficient funding to support this level of scientific evaluation.

Whilst there is undoubtedly room for high quality RCTs to further advance the STH evidence base, other accepted interventions in health and policy fields in the UK have not been based on RCT evidence [ 48 ]. There is also a wealth of quantitative and qualitative evidence from the scientific and VCSE sector advocating the effectiveness of STH, much of which utilises measurable outcomes and describes the impact on the patient (as suggested by the study participants). Furthermore, an independent report by the Kings Fund [ 48 ] suggested that gardening-based interventions can have numerous benefits for individuals as an adjunct to their existing mental health treatment, whilst the Wildlife Trusts [ 49 ] demonstrated significant cost savings to the NHS if they were to invest in a ‘natural’ health service, with an estimated an annual cost of £534.1 million per year for delivery against a gross annual cost saving of £635.6 million. Thus, whilst there is need to strengthen the evidence base in specific areas, there is clear evidence of the potential benefit of NBIs such as STH to the health care system and patients. Furthermore, Wye et al. [ 50 ] reported that commissioners experience multiple barriers to using academic research to inform commissioning. As a result, they often utilise NICE guidelines, local evaluations, local clinicians’ knowledge, and service users experiences to inform their commissioning decisions. To support commissioning of STH, existing evidence and knowledge should be integrated into mental health care policy and practice, NICE guidelines, and be more clearly publicised and communicated to commissioners via effective dissemination methods such as infographics and via professional journals aimed at commissioners.

The findings of this study present the perspectives of nine individuals, from a range of commissioning roles and regions across the UK. However, the full range of barriers experienced by individuals with roles in mental health care commissioning may not have been captured. Further research in this field should aim to incorporate the perspectives of individuals involved in the development of mental health policy and NHS senior leaders who have a direct influence on funding decisions, to understand the barriers to prioritising approaches such as STH at a national level. It should also prioritise high quality RCTs for mental health levels 2–4 and for specific conditions, to develop a clearer and more focused evidence base to support commissioning of STH in mental healthcare. The potential solutions to the commissioning barriers highlighted in this research should also be actioned by individuals in health and VCSE sectors to further support the growth and commissioning of STH. This is essential for ensuring a more sustainable mental health system whereby service users can access support when it is needed.

Overall, the findings of this study highlight a range of barriers to the commissioning of STH, including a commissioning culture which priorities traditional medical models, a lack of knowledge of STH broadly (including the services available, levels of mental health need it can cater for and the existing evidence of its effectiveness, particularly for specific mental health conditions), and the challenges for STH providers in responding to large-scale commissioning requirements. To support commissioning of STH in mental health care, the VCSE sector should be supported in developing higher quality evaluation methodology accepted by the NHS and in working collaboratively to enable commissioning of services at scale. Information on STH services and their effectiveness also needs to be easily accessible to practitioners, and STH interventions should be fully embedded within NHS priorities to enable a more holistic health care approach, which has the potential to improve patient outcomes, reduce the strain on mental health services and result in considerable cost savings.

Availability of data and materials

The datasets generated during the current study are available in the REShare repository, with restricted access via https://reshare.ukdataservice.ac.uk/856812/ .

Abbreviations

Cognitive Behavioural Therapy

General Practitioner

Green Social Prescribing

Integrated Care Board

Integrated Care System

Nature-based Intervention

National Health Service

Randomised Controlled Trial

Social and Therapeutic Horticulture

Voluntary, Community and Social Enterprise

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Acknowledgements

The authors like to acknowledge the funder who enabled this study to take place and the participants for their valuable insights. We would also like to thank the THSG for their help with recruitment of participants to the study.

This work was funded by Research England (grant number FN02200).

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CW, KR and RB conceived and designed the study. GM collected, analysed, and interpreted the data. CW also analysed and interpreted the data and drafted the manuscript. GM, KR, BB and RB substantially revised the manuscript. All authors have approved the submitted version.

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Wood, C.J., Morton, G., Rossiter, K. et al. A qualitative study of the barriers to commissioning social and therapeutic horticulture in mental health care. BMC Public Health 24 , 1197 (2024). https://doi.org/10.1186/s12889-024-18621-8

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“An enormous benefit of VR-based training is that it allows nurse learners to engage in more frequent practice before they encounter real patients, including in rare, specialized, or critical cases,” said UbiSim Lead Nurse Educator Christine Vogel, MSN, RN, CHSE, CHSOS . “We see the new scenarios as part of our ongoing commitment to prepare nurse learners for safe and effective care for all patients, which includes practicing sensitive therapeutic communications in situations and with people that may extend beyond their previous life experiences.”

The two new scenarios in the UbiSim catalog have the goal of preparing nurse learners to approach transgender patients with sensitivity and respect, and to treat Alzheimer’s dementia sufferers with patience and consideration.

• Alzheimer’s Disease: Patient Morgan Therin, an older Black man, is experiencing agitation and refusing care due to Alzheimer's disease. Learners practice administering medications and providing therapeutic communication to assist Morgan in this scenario that aligns with Nursing Fundamentals. Research by the Alzheimer’s Association finds that older Black Americans are “twice as likely as older Whites to have Alzheimer's or another dementia” for still-undetermined causes, and half have experienced discrimination while seeking care for a person living with Alzheimer's.
• Acute Abdominal Pain: Learners care for Skylar Holmes, a male transgender patient, to practice providing therapeutic communication and nursing care that are sensitive, respectful, and inclusive in this scenario that aligns with Medical-Surgical 1. A new Kaiser Family Foundation (KFF) report found that lesbian, gay, bisexual and transgender (LGBT) adults are “twice as likely as non-LGBT adults to report negative experiences while receiving health care” including being treated unfairly or with disrespect, which made them less likely to seek health care or caused them to switch health care providers.

As part of the UbiSim commitment to scenario diversity and inclusion, a previous platform update added male transgender undergarments in an Obstetrics patient scenario. The option of a gray chest binder and briefs in addition to the previously default pink maternity wear is intended to be representative of a transgender patient who has not undergone gender-affirming surgery.

“Within Labster, our dedication resonates strongly with expanding pathways to inclusive learning via immersive digital engagements in STEM and healthcare,” articulated Shawn Boom, chief executive officer of Labster and parent company of UbiSim. “As we advance and diversify the UbiSim scenario portfolio, our commitment to thoughtfully crafted educational experiences persists. We aim to empower nursing students in their readiness to navigate real-life situations with individuals of diverse backgrounds—embracing patients of all ages, races, ethnicities, genders, and cognitive abilities. We believe this approach will help students enhance their therapeutic communication and elevate their standards of patient care.”

Customizing scenarios

A distinguishing feature of the UbiSim platform is that it enables educators without knowledge of programming or coding to create new VR scenarios and customize existing VR scenarios. For example, scenario creators can select patient, family, and caregiver characters from the existing UbiSim catalog representing a diverse group of races and ethnicities, allowing nurse educators to offer students more opportunities to practice offering culturally competent care.

In addition to the two new scenarios, updates to the UbiSim platform include a major new functionality related to the UbiSim intuitive editor. This innovation introduces a nasogastric (NG) tube, a medical catheter inserted through the nose into the stomach in which gastric suctioning can also be performed. Nurse educators can now customize their UbiSim nursing scenarios by adding an NG tube, while nurse learners are able to install an NG tube on any patient within the simulations.

More details on how UbiSim helps nurse learners prepare for the complexities of clinical practice are available by scheduling a demonstration , subscribing to the UbiSim newsletter on LinkedIn , or visiting UbiSim in booth 417 at the annual INACSL Conference June 12-15, 2024, in Raleigh, North Carolina.

About UbiSim

UbiSim™ is the leading immersive virtual reality (VR) training platform dedicated specifically to nursing by Labster. By combining evidence-based immersive VR simulations with an intuitive, web-based authoring tool, UbiSim empowers faculty to customize and design simulations that are curated for their students' learning objectives and align with Next Generation NCLEX test plan and AACN Essentials domains. UbiSim is in use at hundreds of nursing institutions in North America and Europe to advance the shared mission of addressing the nursing shortage by reducing the cost, time, and logistical challenges of traditional simulation methods and scaling high-quality nursing education. Founded in 2016, UbiSim was acquired by Labster® ( www.labster.com ) in 2021 and was named the Gold winner of the Merit Awards for Healthcare in 2023. Visit www.ubisimvr.com .

Julia Stevens Sterling Communications [email protected]

View source version on businesswire.com: https://www.businesswire.com/news/home/20240430278083/en/

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