The relation of intention, skill and communication behavior of an experienced counselor in psychiatric nursing counseling－Targeting the counseling of a depressive client－

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Therelationofintention,skillandcommunicationbehavior

ofanexperiencedcounselorinpsychiatricnursingcounseling

－Targetingthecounselingofadepressiveclient－

精神科看護カウンセリングにおける、意図、技法そして態度の関連

－うつ状態の患者への対応－

MasashiKAWANO

１）

,IkukoNORO

２）

川野雅資・野呂幾久子

Abst

r

act

Thepurposeofthisstudywastoexploretherelationamongintention,skillandcommunicationbehaviorof anexperiencedpsychiatricnursingcounselorinthecounselingofadepressiveclient.A videotapeofthe counselingwasrecordedandthedialogueofthecounselorwasclassifiedtocommunicationbehavior,skilland intention.Inthecounseling,thecounselorcreatedatrustrelationusingtheintention“Existinaneutralposition anddraw concernsothattheclientcantalkfreelyfrom anequalbasis”or“Understandwhattheclientwas goingthrough,hisagonyorpleasureandexpressempathy”byusingtheskillof{Accept}whichwasexpressed bythecommunicationbehaviorof[Agreement].OnceitwasfoundoutthatMr.A wasinacriticalsituationin theconversationintendedto“Diagnosethemedicalcondition”,thecounselor“Expressedhisopinion”thatthe clientshould behospitalized immediately by theskillof{Expresstheopinion ofthecounselor}with the communicationbehaviorof[Informationgiving]or[Counsel].Thenthecounselor“Assistedtheclient”totake thenecessaryprocessforhospitalization,aswellastochangetheperceptiveoftheclientthatitwasnotdueto him butthemanager.Otherrelationswerealsoseenwherethecounselorachievedintentionsbyusingseveral skillsandtheskillswereexpressedbyseveralkindsofcommunicationbehaviors.

Otherrelationswerealsoseenwherethecounselorachievedmanyintentionsbyusingseveralskillsandthe skillswereexpressedbyseveralcommunicationbehaviors.Thisisactuallywhatthecounselorsaredoingin theircounselingthoughitwouldhavesignificanceinunderstandingwhataneffectivecounselingwouldbeby sortingoutandreviewingthroughanobjectivemethod.

Keywords：intention,skill,communicationbehavior,RIAS,depressiveclient

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Thegoalofcounselinginpsychiatricnursingisthat“theclientshouldfeeltrustandasenseofsecurityabout hiscounseloranddeveloparelationshiptobeabletotalkabouthis/heranxiety,concernanddistresswithout

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thefearofrejection”１） _{and“toreducethepai}_nofthecl_i_{entandtosupporttobeabl}_{etoadvancepersonal}

relationshipandparticipateincivillife”１）_.Whi_l_econsi_deri_ngthecl_i_ent’_soccasi_onalcondi_ti_onsandf_eel_i_ngs,the

counselorwillfaceclientsineachsituationwiththe“intention”tomeethis/hergoaleventually.Forexample,if aclientwouldsaythathewouldliketodisappearthecounselorwouldinitiateaconversationtofindoutinhow muchseriousconditiontheclientisin.Inthissituation,theintentionoftheconversationistodiagnosethe medicalcondition.Detailis needed to diagnose the medicalcondition thus the counselor may retrieve informationbyusinga“skill”toaskquestion,suchas“Whywouldyouthinklikethat?”.Theskillchosenbythe counselorisproducedasa“communicationbehavior”.Forexample,thecommunicationbehavior“Whywould you think likethat?”iscalled “open-ended question”which isan unstructured question in which possible answersarenotsuggested.Thus,theconversationofacounselorinpsychiatricnursingcounselingconsistsof threeelementswhichareintention,skillandcommunicationbehavior.Whendiagnosingtheclient’smedical condition asin the above example,however,one may use the skillto draw outfurtherinformation by encouragingtheconversation(e.g.“Pleaseproceed.”)besideofaskingaquestion.Thereisalsoachancethatthe communicationbehaviorisusedastheconfirmationaboutwhattheclienthasalreadymentioned,namely“You wouldliketodisappear,isthatwhatyouaresaying?”.Theremaybevariouskindsofrelationofintention,skill and communication behavior.Itisbelieved thatan experienced psychiatricnursing counselorknowsthe relationswellandiscapabletousethethreeelementsinafreeandeffectivemannerduringcounseling.But therehasbeen nostudy reported which would explain abouttherelationsofthosethreeelementsin a structuredwaysofar.Toshedlighttotherelationamongintention,skillandcommunicationbehaviorwould revealthestructureofaneffectiveconversationofanexperiencedpsychiatricnursingcounselorandmay provideabasicdatatotheless-experienced.

Based on this perspective,Noro et al(2015)２） _anal_{yzed the counsel}_i_{ng f}_{or a cl}_i_{ent suf}_f_eri_{ng f}_rom

schizophreniatofindouttherelationsbetweenintentionandskillaswellastherelationsbetweenskilland communicationbehavior.Inthisstudy,afurtherstudywasmadeaboutthecounselingforadepressiveclient byanexperiencednursingcounselortoexaminetherelationamongintentionskillandcommunicationbehavior.

Ⅱ Met

hod

１ Subjectandsituation

A videotapeofacounselingrecordedonMay2014wasanalyzedwhichlastsforabout57minutes.The counselorisamaleinhissixtieswhoreceivedhisprofessionaleducationinagraduateschoolandhasmore than30yearsofexperienceinthedepartmentofpsychiatricnursing.Theclient(Mr.A)isamaleinhisfifties wholivesinhishouseandattendsthecounselingonaperiodicbasis.

Thescenesconsistofthefollowingsituations:Mr.A whotookatemporaryleavefordepressionandjust returnedtoworkisafraidofhismanagerwhoisconstantlyrunningMr.A down.Mr.A feelsthathedoesn’tfit inthecompanyandfightsagainsttheconflictthathemightlosehisjobifhewouldtakealeavenexttime

１）_{NaragakuenUni}_versi_ty

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whichwouldcausetroubletohisfamily.Feelingsorryforhisfamilyandfeelingguiltyabouthisworthlessness makeshim looseconfidenceabouthimselfandstartstothinkaboutself-destruction.Inthecounseling,the counselorislistening toMr.A carefully tounderstand Mr.A’spain and recommendstoreceivehospital treatmentandtobehospitalized.

２ Procedures

The study protocolwas reviewed and approved by the InstitutionalReview Board ofSanyogakuen University.Theproceduresofthisstudyareasfollows;1)dividethedialogueofcounselorintoasmallunitand classifyeachunitintocommunicationbehavior,2)classifyeachunitintoskill,3)classifyeachunitintointention, 4)countthenumberofunitsineachcommunicationbehavior,skillandintention,5)examinetherelationsofthe threeelementsbyprovidinganexample.

１）Classificationofthecommunicationbehavior

NoroclassifiedthecommunicationbehaviorwhilereferringtoRoterInteractionAnalysisSystem (RIAS)３）_.

RIASisacodingsystem themostworldwidelyusedtocodethecommunicationbehaviorofmedicalvisit.The feasibility and validity ofapplying theRIAS toJapanesemedicalconversationshasbeen investigated and confirmedbyIshikawaetal４）_.TheRIASuni_tofanal_ysi_si_scal_l_{ed“utterance”,acompl}_{etethoughtdef}_i_nedas

thesmallestdiscriminablespeechsegmenttowhichacodeclassificationmaybeassigned３）_{.Codesaremutual}_l_y

exclusiveandexhaustivesothateveryexpressedthoughtisassignedtoonlyonecategorythatreflectsthe communicationbehavior.

２）Classificationofskill

Kawanoclassified each utteranceofthecounselorby referencing thetherapeuticcommunication skills１）

underskill.Therapeuticcommunication skillsdonotspecify aboutthedefinition ofeach skillthusitwas definedbyKawanobasedonthestudyofNoroetal(2015)２）_.Whenaski_l_{lappeared,whi}_chdi_dnotappeari_n

thestudyofNoroetal(2015)２）_,i_twasdef_i_{nedbyKawanoandaddedasanew one.}

３）Classificationofintention

Again,Kawanowhohasperformedthecounselinggroupedeachutteranceofthecounselorbyreviewingthe intention.KawanohasgroupedanddefinedtheintentionbasedonNoroetal(2015)２）_{andcametoaconcl}_usi_on

byreviewingwithKawano.Whenanew intentionwasfoundinthiscounseling,Kawanodefineditandaddedit asanew one.

Ⅲ Resul

tandDi

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１ Communicationbehaviorofthecounselorduringthecounseling

The totalnumberofutterance made by the counselorwas306.Table 1 indicatesthe communication behavior,the definition,numberofutterances,and percentage to the totalnumberofutterancesofthe

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counselorinthiscounseling.

“Agreement”isthemostseenwhichcoversalmostthehalfwith147utterances(48%).Itisanutteranceto indicatethatthecounselorislistening,agreeingorunderstandingMr.A’stalk.Itcanbeconcludedthatthe counselorwasindicating alotofutterancestolisten and accepttheMr.A’sagony.“Information giving” covered9.2% whenputtingtogetherwith“Counsel”wherebothcontentscovered17.4% inthiscounseling.This canbeconcludedfrom thefactthatthecounselingscenesconsistedofMr.A inasurvivalsituationwherethe counselorhadtoinform thecurrentsituationorsolutionandtherewasaneedtoadviseMr.A abouttheway ofacting.

２ Theskillusedduringthecounselingbythecounselor

Next,skillsusedinthisstudyincludingthedefinition,numberofutterancesandthepercentagetothetotal numberofutterancesareshowninTable2.

% Numberof utterances Definition Communication behavior 1.0 3

Greetings,conversationonnon-medicaltopic. Personal 1.3 4 Laughter,tellsjokes. Laughs 48.0 147

Showsagreementorunderstanding.Indicatorsofsustainedinterest,attentivelisteningor encouragement.

Agreement

2.6 8

Showsdisapproval,criticism,complaint,rejection. Disagreement 1.0 3 Apologies Remediation 4.2 13

Statementsthatparaphrase,interpret,nameorrecognizetheemotionalstateoftheclient. Statementsthatindicatethattheclient’semotionalsituation,actions,orthoughtsare understandableandnormal.

Empathy

1.3 4

Statementsindicating thata condition oreventisserious,worrisome,distressing or deservingspecialattentionandisofparticularconcernatthispointintime.

Concern

2.6 8

Statementsindicatingoptimism,encouragement,reliefofworryorreassurance. Reassure

0.3 1

Statementsthatconveythecounselor’salliancewiththeclientintermsofhelpandsupport, decision-making,orthedevelopmentofthetherapeuticplan.

Partner

9.2 28

Statementsthatdonotexplicitlydirectclient’sbehavior.Characterizedbycontentpresented inaneutralmanner.

Informationgiving

8.2 25

A counselorissuggestingwhattheclientshoulddooraboutthesolution.Characterizedby theintentiontoconvincetochangethebehaviorortoorprovideinstructionstotheclient. Includestheimperativestatementlike“Youshould~”.

Counsel

1.0 3

Questionswhichcannotbeansweredby“Yes”,“No”orinawordortwo. Open-endedquestion

3.9 12

A directlyaskedquestiontoinquireaboutsomethingspecificwhichcanbeansweredby “Yes”,“No”orinawordortwo.

Closed-endedquestion

3.3 10

Torepeattheclient’swordsbyasking“Isthiscorrect?”toconfirm ifthecounselor’s understandingiscorrectandsharingthesamevision.

Check

2.3 7

Anexpressiontorequestclient’sopinion,permissionfrom theclientandrepetitionofclient’s previousstatements.

Request

2.3 7

Asktheclienttodosomethinglike“Please~”ortotelltheclientaboutwhatisgoingto happenlike“Iam goingto~”.

Givesorientation

2.0 6

A signtomovetoanotherbehavior,makinganunmeaningfulsoundtokeeptheinitiativeof theutterance.

Transitionwords

5.6 17

Silenceofacertainleveloflength. Silence

100 306

Total

Table1 Communicationbehaviorsofthecounselorduringthecounseling

% Numberof utterances Definition Skill 3.6 11

Questionsinanopenorclosedwayusingwordstomakeiteasyfortheclienttotalk. Question

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The skillof“Accept”wasthe mostused with 84 utterances(27.5%)and followed by “Encourage the conversation”(21.6%).Usingthoseskills,thecounselorwassendingamessagetoMr.A thatheislisteningand acceptingandwouldliketoproceedwiththeconversation.Ontheonehand,thecounselorwasexpressinghis opinionaboutMr.A’ssituationusingthe“Expresstheopinionofthecounselor”skill(10.8%).Thecounselor providedasolutiontoMr.A usingthe“Provideinformation/suggestion”skill(9.5%).

３ Theintentionofthecounselorduringthecounseling

Table3indicatestheintention,thedefinition,numberofutteranceandthepercentageoftheutterancetothe total.

27.5 84

Expressempathytotheclientthatthecounselorislisteningtowhatwassaidand whatwassaidhasavalidpoint.

Accept

21.6 66

Expressverbal/non-verbalmessagestomaketheclienteasiertotalk. Encouragetheconversation

5.6 17

Arrangesomeutterancefortheclienttotalkabouthisfeeling.Expresstheintention ofthecounselorthatthereisnoneedforaconversationorshowtheimportanceofthe utterancespendingtogether.

Effectivesilence

0.3 1

Questiontheclienttoexpresshisfeeling.Thecounselormaymurmurthefeelingof theclientbyengaginginself-questioning.

Encouragetheclienttoexpress hisfeeling

4.9 15

Questiontheclienttoexpresshisopinion.Thecounselormaymurmurhisopinionof theclientbyengaginginself-questioning.

Encouragetheclienttoexpress hisopinion

1.0 3

Counselorexpressesthefeelingwhenhereactedtotheclient'sexperience. Express the feeling of the

counselor

10.8 33

Counselorexpressestheopinionabouttheclient'sexperience. Express the opinion of the

counselor

1.0 3

Expressinwordsaboutthegoodpoints(opinion,behavior,characteretc.)ormaking efforts.

Tellthegoodpoints

1.0 3

Expressthegruelingexperienceoftheclientasajokeorturnitintoasmile. Expresshumor

5.9 18

Talkaboutwhatiscurrentlygoingonandwhatneedstobedonenow. Statethereality

9.5 29

Thecounselorinformsaboutwhatisnecessary totheclientand statesseveral solutionsornecessarymeasures

Provideinformation/suggestion

2.6 8

Thecounseloragreestotheclient'sopinion,behaviororaction. Agree

1.3 4

Thecounselorinownwordslooksfrom theclient'spointofpositionandview to expresswhattheclienthasn'tmentionedyet.

Representation

1.0 3

Thecounselorleadsandtalksfortheeaseoftheclient'saction. Guidance

0.7 2

Repeatwhattheclienthasexpressedusingsamewords. Repeat

0.7 2

Asktheclientaboutthecounselor'sunderstandingtobeappropriateornot. Confirmation

0.3 1

Useanotherwordwiththesamemeaningtoexpresswhattheclienthasmentioned. Paraphrase

0.3 1

Expressthecounselor'smistake,errororfailureinadirectfashion. Apologize

0.3 1

Thecounselorisaskingtheclientforpermissionabouttheactionheisabouttotaketo beappropriateornot.

Permit

0.3 1

Thecounseloronceacceptswhenaclientasksforanadviceorimplicateabouthis thoughts,opinionsoractions.Inthatcase,thetopicwon'tbedealtfornow andthe focuswillbeshiftedtoanothertopic.

Shelvedplan 100 306 Total % Numberof utterances Definition(Goaloftheintention,theexistentialreason,idea,result,aim,contentetc.)

Intention

2.9 9

Toorganizeaspaceoftherapyandcomfortfortheclienttorealize.Tocreateapeaceful moodandtoreturntonormalone'sself,i.e.relaxationoftension,ahumortogetintune, haveacomfortabletalkandcreateanatmosphere.

Creating a peaceful atmosphere

3.9 12

Show theheartofhospitalityaswellashow muchimportant,valuablehumanbeingthe clientisandtreathim assuch.Thisistoincreasethesenseofself-respectoftheclient.In particular,expressviaverbal/non-verbalmeans,goodsandenvironmentthattheclientis animportantexistenceasahumanbeing.

Show respecttotheclient asahumanbeing

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Themostseenintentionthecounselorusedwas“Existinaneutralpositionanddraw concernsothatthe clientcantalkfreelyfrom anequalbasis”whichwasalmostthehalfthetotal(46.4%).Secondly“Understand whattheclientwasgoing through,hisagony orpleasureand expressempathy (16.0%).Taking thisinto consideration,itcanbeconcludedthatmorethan60% oftheutteranceswereconsumedbythecounselorto acceptandlistentoMr.A withoutcriticism,relivehisagonyandexpressthefeelingwhichweregeneratedin thatcounseling.Inadditiontothealreadyestablishedtrustfrom Mr.A tothecounselorasin“Ithoughtthat youneverwouldcriticizemelikethat.”or“Iwastryinghardtocarryonlivingtomeetyoutoday,justlike that.”,itissuchkindofattitudeofthecounselorwhichembracedthecomfort,trustandbondtobeacceptedto encourageMr.A tospeakatitsowninitiative.

46.4 142

Uncriticallyreacttotheclient'sagonyinaseriousmanner.Oncetheclientexpresseshis feeling willactas a catalystofchange to his preference,fixation or obsession. Additionally,theclientwillhaveakeendesiretotrustthecounselorwhichleadstoa feelingofsecurity.Inparticular,communicatetotheclientinbothaverbalandnon-verbal mannerthateverysingleexperienceismeaningfulandhasitsvaluetopreventtheclient from stoptalking.Thecounselorshouldlistencarefullytotheclient'sexperienceand respondbybody-language,theninquirefurtherabouttheclient'sexperiencetobeableto expressabouttheaffectionofit.Itisimportanttoindicateviaverbally/non-verbally meansthattheclientwasabletomakehispointtothecounselorfreely.

Existin a neutralposition and draw concern so that theclientcantalkfreelyon anequalbasis

16.0 49

Relivetheexperienceoftheclient,expressthefeelingofthecounselor.Thisistobecome emotionallyaccessiblewiththecounselorbysharingtheirexperienceandtofreethem up from desolationandbecomeobjectiveaboutthesituation.Inparticular,theclientwill explainabouthisownexperiencetothegroundsothatthecounselorwillbeabletorelive theirexperience(i.e.asitwasexperienceddirectlybythecounselor).Thecounselorthen willexpresstheirfeelingatthatpoint.Inanswertotheclient'sexperience,thecounselor willexpresshisfeeling.

Understandwhattheclient was going through, his agony or pleasure and expressempathy

3.3 10

Toavoidsituationslikeescapeofmemory,incomprehensibility,suspicionandanxiety,the counselorneedstoprovideinformationandexplainabouthisideaandbehaviorabout whatactionsaclientneedstotakeinacomprehensiblemanner.Ifnecessary,itis recommendedtotakenotes.Toassistclientstotakenotesoruseelectronicdevicesto avoidescapeofmemoryorconfusion.Motivationofactionisrecommendedifnecessary. Shakeoffanxiety

6.2 19

Thecounselormustunderstandthecondition/medicalconditionsothattheclientisable tounderstandhiscondition/medicalcondition.Inparticular,questionasanexpertto assess,ifnecessarytoexplaintheresultsviawordsorgraphicdisplaysothattheclient canunderstand.

Diagnose medicalcondition andstateittotheclient

14.4 44

Wouldopenuptothinkobjectivelyabouttheabnormalexperiencewhenpointedout.In consequence,the reaction to the medicalcondition would change.The clientwill understandthatamedicaltreatmentismandatoryjustasmuchascounselingwiththe primarydoctor.Inprimary,thecounselorshouldexpresshisdecisionandopiniondirectly. Sometimes,itmaybenecessarytopointoutabouttheabnormalexperienceoftheclient. Expresstheopinion ofthe

counselor,commentandjust argument

6.2 19

Understand,expressunderstandingorproposetheclient'slivingconditionandopinion. Affirm andmotivate,encourageandbackupsothattheclientwouldfurthermorechange hisbehavior.Substantiate resolution behavior,think together.Help to change the viewpointand way ofthinking.Question abouttheclient'slife,behavior,reason of behaviorandanxiety.Checktheclient'sbehavior.Thisistoencouragethechangeof cognitionandbehaviorandtogainproblem-solvingthoughtsandbehavior.Thiswilllet theclientthinkobjectively,remindtodoallkindofthinkingandchangetheissueinlife.In particular,itindicatesthedecisionofthecounseloraboutthegoodwayofthinking, behavior,changeorcopingprocessoftheclientinanexplicit,inaclearandsometimes stronglyemphasizedasverygoodway.Askingquestionsindetailandwhentheclientis talkingabouthislifeinparticulardetail(narrative)thecounselorwillexpressina verbal/non-verbalmannerthathehasunderstoodwhatwastold.Bythinkingtogether aboutasolution,thecounselorwillprovideanopinionsothattheclienthasachanceto choosewhichsolutiontoselect.Reachouttocognitiontopresentthatthereareother waysofthinking,pointofviews.Sometimes,itmaybenecessarytoquestionwhythe clientunderstoodthesituationthatwayandtoillustratethatthereareothermeanings. Thecounselorneedstocreateanenvironmentandquestiontheclientinaverbal /non-verbalmannersothattheclientcanfreelytalkandthatthereisnoneedtoconcealhis opinion.Questiontheclientinawaysothathecantellabouthisbehaviorindetail. Assistthe client's opinion,

behavior,changeorcoping processandencouragehim togetbettersoon

0.7 2

Nospecialmeaningswhichwereexpressedbytheflowofabehaviororconversationina spontaneouswayasaTransitionwordssound.Asocialresponse.

Other

100 306

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Undersuchrelationship,thecounselorsteppedintofortreatment.Itwasjudgedthatthiswasacritical situationwhereMr.A wouldcommitsuicidethusitservedtoconsidertheunderstandingofMr.A (Intention “Diagnosemedicalconditionandstateittotheclient”(6.2%)).ItwasthencommunicatedimmediatelytoMr.A tobehospitalized(Intention“Expresstheopinionofthecounselor”(14.4%)).

４ Relationofintention,skillandcommunicationbehavior

Therelationofintention,skillandcommunicationbehaviorissummarizedasintable4.

Numberof utterances Communicationbehavior

% Numberof utterances Skill Intention 3 Laughs 33.3 3 Expresshumor Creatingapeacefulatmosphere(9)

3 Disagreement 33.3 3 Statethereality 1 Silence 11.1 1

Effectivesilence

1 Disagreement 11.1 1 Expressestheopinionofthecounselor 1 Givesorientation 11.1 1 Guidance 2 Personal 25.0 3 Accept

Show respect to the client as a humanbeing (12)

1 Agreement

1 Informationgiving

16.7 2

1 Givesorientation 1 Personal 16.7 2 Guidance 1 Givesorientation 1 Request 8.3 1 Question 1 Remediation 8.3 1 Expresstheopinionofthecounselor 1 Informationgiving

8.3 1 Statethereality 1 Remediation 8.3 1 Apologize 1 Givesorientation 8.3 1 Permit 62 Agreement 45.1 64 Accept

Existinaneutralpositionanddraw concernsothattheclientcantalk freelyfrom anequalbasis(142)

1 Check 1 Request 51 Agreement 38.7 55 Encouragetheconversation 1 Remediation 1 Concern 1 Givesorientation 1 Request 4 Closed-endedquestion 6.3 9 Question Check 3 1 Open-endedquestion 1 Transitionwords 6 Silence 4.2 6

Effectivesilence

1 Closed-endedquestion 1.4

2 Encouragetheclienttoexpresshisopinion

1 Open-endedquestion 2 Agreement 1.4 2 Agree 1 Check 0.7 1 Repeat 1 Check 0.7 1 Paraphrase 1 Check 0.7 1 Confirmation 1 Disagreement 0.7 1 Shelvedplan 13 Agreement 30.6 15 Accept

Understand what the client was goingthrough,hisagonyorpleasure andexpressempathy(49) 1 Empathy 1 Concern 10 Agreement 22.4 11 Encouragetheconversation 1 Empathy 9 Silence 18.4 9

Effectivesilence

2 Empathy 6.1 3 Expresstheopinionofthecounselor 1 Disagreement 2 Concern 6.1 3 Agree 1 Agreement 3 Empathy 6.1 3 Representation 2 Empathy 4.1 2

Expressthefeelingofthecounselor

1 Agreement

4.1 2

Encouragetheclienttoexpresshisopinion

1 Closed-endedquestion 1 Empathy 2.0 1

Encouragetheclienttoexpresshisfeeling

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Wearenow goingthrougheachintentiontoexaminetherelationwiththeskillandthecommunication behaviorby providing an example.In theexamples,theskillsaresurrounded by {},thecommunication behaviorby[].(Example:{Expresshumor}-[Laughs]indicatesthattheskillof{Expresshumor}isexpressedby thecommunicationbehavior[Laughs])

１）Existinaneutralpositionanddraw concernsothattheclientcantalkfreelyfrom anequalbasis Themostseenskillofthisintentionwas{Accept}whichindicatesthatthecounselorwaslisteningoroffered

5 Informationgiving

60.0 6

Provideinformation/suggestion Shakeoffanxiety(10)

1 Reassure 1 Reassure 20.0 2

Expresstheopinionofthecounselor _Counsel ₁ 1 Reassure 10.0 1 Statethereality 1 Reassure 10.0 1 Agree 4 Informationgiving

42.1 8

Diagnosemedicalconditionandstate ittotheclient(19) 4 Counsel 2 Counsel 36.8 7

2 Transitionwords 1 Open-endedquestion 1 Closed-endedquestion 1 Request 2 Counsel 10.5 2 Expresstheopinionofthecounselor 1 Agreement 5.3 1 Accept 1 Empathy 5.3 1 Representation 10 Counsel 52.3 23 Expresstheopinionofthecounselor

Expresstheopinionofthecounselor, commentandjustargument(44)

7 Informationgiving

2 Empathy 1 Disagreement 1 Reassure 1 Partner 1 Givesorientation 4 Informationgiving

20.5 9

Provideinformation/suggestion Counsel_Transi_ti_onwords 2₂ 1 Check

3 Informationgiving

15.9 7 Statethereality 1 Agreement 1 Disagreement 1 Check 1 Transitionwords 3 Reassure 6.8 3 Tellthegoodpoints 1 Closed-endedquestion 2.3 1 Confirmation 1 Check 2.3 1 Repeat 1 Laughs 26.3 5 Statethereality

Assisttheclient'sopinion,behavior, change or coping process and encouragehim togetbettersoon(19)

1 Agreement

1 Informationgiving

1 Closed-endedquestion

1 Counsel

2 Informationgiving

21.1 4

Provideinformation/suggestion Counsel 1 1 Givesorientation 2 Closed-endedquestion 15.8 3

Encouragetheclienttoexpresshisopinion _Request ₁ 2 Counsel 10.5 2 Expresstheopinionofthecounselor 2 Agreement 10.5 2 Agree 1 Agreement 5.3 1 Accept 1 Closed-endedquestion 5.3 1 Question 1 Silence 5.3 1

Effectivesilence

1 Request

50.0 1

Other(2) _Statethereal_i_ty ₁ _50.₀ _Request ₁

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thumbsupaboutwhatMr.A hasmentioned(64utterances,45.1%).Secondly{Encouragetheconversation}via verbalornon-verbalmessagesothatMr.A couldfinditeasytoexpresshimself(55utterances,38.7%)followed by {Question}wherethecounselorasked aquestion (9utterances,6.3%).Mostoftheskillsof{Accept}or {Encouragetheconversation}wereexpressedbythecommunicationbehaviorof[Agreement],statementsto show agreementorunderstandofwhatMr.A hasmentionedorviaasupportiveresponse.

The<Example1>indicatesthebeginningofthecounseling.ThecounselorwastoldoverthephonebyMr. A thathewashavingdifficultiesatthecompanywhenreturnedwherehesufferedfrom adepressionandhad totakealeaveofabsencefrom hisjob.Tocollectextensiveamountsofinformation,thecounselorasked questionsbyusingthecommunicationbehaviorof[Open-endedquestion]tomakeiteasierforMr.A totalk aboutthis.Afterthat,thecounselorencouragedMr.A totalkandexpressedthathehasacceptedthefeeling ofMr.A by[Agreement].

Ns:Yourstartdaywasonthe7thandhow iseverythinggoingsincethen? {Question}-[Open-endedquestion] Cl:Well,(3secondsofsilence)Isomehow knew itwillendupthisway(Takingadeepbreath)

Ns:Yah{Encouragetheconversation}-[Agreement]

Cl:It’slikeeverythingisfallingapart(10secondsofsilence) Ns:Hmm.{Accept}-[Agreement]

Otherthanthe[Open-endedquestion],theskillof{Question}wasexpressed4timesin[Closed-endedquestion] where a question wasasked which could be answered by justa “yes”or“no”to retrieve a particular informationfrom Mr.A,and3timesbythecommunicationbehaviorof[Check]torepeatwhatMr.A has mentionedandtoconfirm ifthecounselor’sunderstandingwascorrectornot.<Example2and3>indicatesthe serious-minded approach of the counselor to listen to Mr.A’s story by asking questions using the communicationbehaviorof[Closed-endedquestion]or[Check].

Ns:(Eachandeveryday,Mr.A wasfacedwithcriticism bythewordsofthemanager:“Youbetterbethe factoryheadifyouwanttokeepyourcurrentsalary”,towhichthecounselorresponds)Mr.A,whendoes yourmanagersaysuchathing?{Question}-[Closed-endedquestion]

Ns:(ThecounselorreactingtowhatMr.A toldaboutwhathismanagerhadmentioned:“Mr.A’sconditiongot evenworsebecauseofanindulgentcounselor”) Didhereallysaythat?{Question}-[Check]

２）Understandwhattheclientwasgoingthrough,hisagonyorpleasureandexpressempathy

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{Encouragetheconversation}(11utterances,22.4%)buttheskillof{Effectivesilence}wasusedmostamongall intentiontoprovidetimeforMr.A tothink(9utterances,18.4%).Mostoftheskillsof{Accept}and{Encourage theconversation}wasexpressedby[Agreement]justliketheintentionin1).

<Example4>isthescenewhereMr.A wasexpressinghisguiltbecausehereturnedtoworkbutcouldn’t doanything and causing troubletoothers.By thecommunication behaviorof[Agreement],thecounselor encouragedtotalkandmentionedthathehasacceptedhisagonyonceMr.A hascompletedhisconversation. By inserting an intervalof18seconds,thecounselorshowed an attitudetowaituntilMr.A hasspoken everythingwhatwasonhismind.

Cl:Idon’twantto(sobbing),wanttoputthecompany,myfamilyandyou(2secondsofsilence)toanymore trouble(10secondsofsilence),Ifeelsohelpless(sobbing).

Ns:Yah{Encouragetheconversation}-[Agreement] Ns:(18secondsofsilence){Effectivesilence}-[Silence]

Cl:Iam aware(sobbing)(4secondsofsilence)thatIam givingeveryoneagooddealoftrouble(3secondsof silence)Ifinally(2secondsofsilence)understoodthat.

Ns:Iknow.{Accept}-[Agreement]

Thecommunicationbehaviorof[Empathy]whichshowsempathytoMr.A’sfeelingorshow understanding thatMr.A’sbehaviorisunderstandablewasseen13timesinthiscounseling.10outof13utteranceswereseen in thisintention.<Example5> indicatesthecounselorunderstandsMr.A’sagony and thatheisstaying present.HealsoencouragesMr.A totalkabouthow hefeels.

Ns:Iam reallysorrytohearthat.Youdidverywell.{Expressthefeelingofthecounselor}-[Empathy] Ns:(50secondsofsilence){Effectivesilence}-[Silence]

Ns:WespokeoverthephoneonThursday,didn’twe? {Question}-[Check] Cl:Yes.

Ns:Itmusthavebeenpainfulatthattimeaswell,wasn’tit?{Encouragetheclienttoexpresshisfeeli ng}-[Empathy]

３）Expresstheopinionofthecounselor,commentandjustargument

Theskillof{Expresstheopinionofthecounselor}wherethecounselorexpresseshisopinionaboutMr.A’s experience(23utterances,52.3%)wasseenmostinthisintentionfollowedby{Provideinformation/suggestion} whichprovidesnecessaryinformationtoMr.A orthesolutionprovidedbythecounselor(9utterances,20.5%). TostatehisopiniontoMr.A,thecounselorusedthecommunicationbehaviorof[Counsel]toadviseMr.A whatactionsto take (10 utterances)or[Information giving]to provide information in a neutralway (7

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utterances).Also,to provide information or solution,the counselor used the communication behavior of [Informationgiving](4utterances)or[Counsel](2utterances).

In<Example6>,takingMr.A’scurrentmedicalconditionintoconsideration,thecounselorsensedthatthe currentambulanttreatmentistooriskyandMr.A shouldreceivehospitalizationtherapyimmediatelywhere hisopinionwastoldopenlytoMr.A asanadvice.In<Example7>,thenecessarymethodorprocessfor hospitalizationwasproposedtoMr.A asinformation.

Ns:Mr.A,let’sgetanew start(2secondsofsilence){Expresstheopinionofthecounselor}-[Counsel] Ns:...eliminatedepressiontogether(3secondsofsilence){Expresstheopinionofthecounselor}-[Counsel] Ns:andreturntohealth.{Expresstheopinionofthecounselor}-[Counsel]

Ns:YoutoldmethatyouliveintownD sothefirstoptionwouldbetoapplyforanemergencymedical admissionintownD {Provideinformation/suggestion}-[Counsel]

Ns:orifyoucanwaituntiltomorrow IcancallupsomeoneIknow.{Expresstheopinionofthecounsel or}-[Informationgiving]

Ns:Iam notsureaboutthevacanciesofthehospital.{Expresstheopinionofthecounselor}-[Information giving]

Cl:OK.

Ns:IfyoudecidefortownD (3secondsofsilence){Provideinformation/suggestion}-[Transitionwords] Ns:Youcanbehospitalizedforcertain.{Provideinformation/suggestion}-[Informationgiving]

４）Diagnosemedicalconditionandstateittotheclient

Inthisintention,theskillof{Provideinformation/suggestion}(8utterances,42.1%)or{Encouragetheclientto expresshisopinion}(7utterances,36.8%)wasseenalot.{Provideinformation/suggestion}wasexpressedinthe communicationbehaviorof[Informationgiving](4utterances)and[Counsel](4utterances).

In<Example8>,Mr.A wastellingthathewascriticizedbyhismanagereverydayanddidnotwanttobe inthecompanywherehedidnotfitinorathishomewherehewascausingtroublewhichwashuntinghim down.Thecounselorattemptedtoevaluatethemedicalconditionbyusing[Open-endedquestion]toencourage Mr.A totalkmoreabouthisfeelings.Infact,thecounselordrew outthetruthfrom Mr.A thathewas actuallythinkingtocommitasuicide(“IwishIcoulddisappearfrom thisworld”)whichimplieshewasina criticalcondition.In<Example9>,thecounselorinformedMr.A by[Informationgiving]or[Counsel]thathe concludedthatMr.A needshospitalizationtherapyandaskedforhisunderstanding.

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question] <Example9>

Ns:Whatyouneedistorest{Provideinformation/suggestion}-[Counsel]

Ns:Iwilltry(bymyself)tofindaplaceforyou.{Provideinformation/suggestion}-[Informationgiving] ５）Assisttheclient’sopinion,behavior,changeorcopingprocessandencouragehim togetbettersoon

Themostseenskillinthisintentionwas{Statethereality}whichbringsupwhatwascurrentlygoingon(5 utterances,26.3%)followedby{Provideinformation/suggestion}(4utterances,21.1%),then{Encouragetheclient toexpresshisopinion}(3utterances,15.8%).

The<Example10>dealsaboutthefinalphaseoftheconversation.ThecounselorwasconcernedthatMr.A mightcommitsuicideonhiswayhomeandadvisedinarealisticmannertoaskMr.A togetataxihome,lent him the money who did nothave enough money.In <Example 11>,the counselor daringly used the communicationbehaviorof[Request]torequestanopinionfrom Mr.A whothoughtthatthemanager’sanger wasbecauseofhisworthlessnesswhichledtolow self-esteem ofMr.A.TosupportMr.A tochangehis perspective,thecounseloradvisedMr.A thatitwasnotduetohim butthemanagerwhowasmisdirectinghis angertoMr.A ratherthantohimself.Andin<Example12>,thecounselorexpressedhisopinionbyusing [Counsel]thatMr.A shouldfocusnotonothersbutonsolvinghisagonytoencouragetodirecthisattentionto theproblem resolution.

Ns:Iwillpayforthefare{Statethereality}-[Counsel] <Example11>

Ns:(withrelationtoMr.A aboutthemanagerfilledwithrage)Doyouhaveanyideawhy?{Encouragethe clienttoexpresshisopinion}-[Request]

Cl:Ihavenoclue.

Ns:Ibelieveitisbecausethemanagerisawarethathemadeamistake.{Expresstheopinionofthecounsel or}-[InformationGiving]

Ns:Theangerusedtobemeanttopointagainsthim buthedoesnotfeelresponsiblethustherageisnow pointedatyou.{Expresstheopinionofthecounselor}-[InformationGiving]

Ns:(Aftermentioningthattherewasnoneedtothinkaboutthesurroundings)Itisyouragony(whatweneed tothinkabout){Expresstheopinionofthecounselor}-[Counsel]

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６）Show respecttotheclientasahumanbeing

In thisintention,theskillof{Accept}hasbeen seen most(3utterances,25.0%).In <Example13>,the counselorservedacupofcoffeetoMr.A asasignofwelcomeandexchangedgreetingsbythecommunication behaviorof[Personal])toexpresstheattitudethatMr.A meanssomethingveryimportanttohim.

Cl:Thankyouforthecupofcoffee. Ns:Youarewelcome{Accept}-[Personal] ７）Shakeoffanxiety

Inthisintention,theskillof{Provideinformation/suggestion}wasusedmost(6utterances,60%)withthe communicationbehaviorof[Informationgiving].<Example14> indicatestheconversationjustbeforetheend. Mr.A decidedtoundergohospitalizationtherapy(whichmeanstoleavethecompany)buthadastrongfearto talkaboutitwithhismanager.Thecounselortoldhim thatheisgoingtotalktothemanageronhisbehalfto takeoutfearfrom Mr.A.ForthepeaceofmindofMr.A,thecounseloragreedtonotworryaboutanything bythecommunicationbehaviorof[Reassure]totheresponsetoMr.A whowasaskinghim thathereallydon’t havetoworryaboutanything.

Ns:Iwillcallyoutomorrow {Provideinformation/suggestion}-[Informationgiving] Cl:IsthereanythingIshouldbedoing?

Ns:No{Agree}-[Reassure]

Ns:Allyouhavetodoistostayathomeandrelax{Provideinformation/suggestion}-[Reassure] ８）Creatingapeacefulatmosphere

Despiteofbeingaseriousscenewheretheconceptofsuicidewasrecalled,thecounselorusedtheskillof {Expresshumor}toturnMr.A’sagonyintoajokeorsmile(3utterances,33.3%)inthisintention.Thisskillwas expressedtotallybythecommunicationbehaviorof[Laughs].

<Example15>indicatesasceneaboutthereactionofMr.A’swifeinregardtothecurrentconditionofMr. A.Sofar,Mr.A tookaleaveofabsenceduetodepressiontwice.Heknew thatifhewouldtakeanotherleave, thecompanywouldlethim go.Thoughrightafterhereturnedtowork,hismedicalconditiongotworseand wasnotinastatetokeepworking.ThecounselortoldMr.A whofeltsorryforhiswifethat“Itisnotthefault ofeitherMr.A orhiswifebecausenobodycouldhaveforeseenthatthemedicalconditionwouldtakesucha suddenturntotheworse”.Rightafterthat,thecounselorchuckledfollowedbythesmileofMr.A.Thechuckle ofthecounselorcreated aspacewhereMr.A could feelathomewhich released thetension ofMr.A entrenchedwithagony.

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Ns:Thoughasyourwifementioned,nobodyknew thatit(totakealeaveofabsenceforthethirdtime)would comesoonlikethis.{Expresshumor}-[Laughs]

Cl:Chuckle.

Ⅳ Concl

usi

on

Inthisstudy,weaimedtoexploretherelationoftheintention,skillandthecommunicationbehaviorina counselingforadepressiveclientbyawell-trainedcounselorwhospecializesinpsychiatricnursing.Inthe counseling,thecounselorcreatedatrustrelationusingtheintention“Existinaneutralpositionanddraw concernsothattheclientcantalkfreelyfrom anequalbasis”or“Understandwhattheclientwasgoing through,hisagonyorpleasureandexpressempathy”byusingtheskillof{Accept}whichwasexpressedbythe communicationbehaviorof[Agreement].OnceitwasfoundoutthatMr.A wasinacriticalsituationinthe conversationintendedto“Diagnosethemedicalcondition”,thecounselor“Expressedhisopinion”thattheclient should behospitalized assoon aspossibleby theskillof{Expresstheopinion ofthecounselor}with the communicationbehaviorof[Informationgiving]or[Counsel].Thenthecounselor“Assistedtheclient”totake thenecessaryprocessforhospitalization,aswellastochangetheperceptiveoftheclientthatitwasnotdueto him butthemanager.

Otherrelationswerealsoseenwherethecounselorachievedmanyintentionsbyusingseveralskillsandthe skillswereexpressedbyseveralcommunicationbehaviors.Thisisactuallywhatthecounselorsaredoingin theircounselingthoughitwouldhavesignificanceinunderstandingwhataneffectivecounselingwouldbeby sortingoutandreviewingthroughanobjectivemethod.

Additionalstudieswillbeneeded toincreasethenumberofcounseling tosystematizemuch morethe relation and to deepen the conceptofintention and to sortoutthe classification ofintention,skilland communicationbehaviorwheretherearestillalotofduplicatesbeingseen.

Ref

er

ences

１）KawanoM.ClinicalPracticeofPsychiatricNursing.Tokyo:IGAKU-SHOIN.2005.

２）NoroI,KawanoM,ItoK,KatayamaN andSasakiI.Therelationofcommunicationbehavior,skilland intentioninaninterview ofacounselorinpsychiatricnursing-apilotstudybasedonaninterview ona subjectsufferingfrom schizophrenia-.JournalofDiscourseAnalysisStudyinPsychiatricNursing,3,2015, 13-26.

３）RoterDL& LarsonS.TheRoterinteractionanalysissystem (RIAS):utilityandflexibilityforanalysisof medicalinteractions.PatientEducationandCounseling,46,2002,243-251.

４）IshikawaH,TakayamaT,YamazakiY,SekiY & KatsumataN.Physician-clientcommunicationandclient satisfactioninJapanesecancerconsultation.SocialScienceandMedicine,55,2002,301-311.

The relation of intention, skill and communication behavior of an experienced counselor in psychiatric nursing counseling－Targeting the counseling of a depressive client－