During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, “Now just leave. I told you to stay home. There isn’t enough work here for both of us!” What is the nurse’s best initial response?
A. “When people are under stress, they may see things or hear things that others don’t. Is that what just happened?”
B. “I’m having a difficult time hearing you. Please look at me when you talk.”
C. “There is no one else in the room. What are you doing?”
D. “Who are you talking to? Are you hallucinating?”
Correct Answer: A. “When people are under stress, they may see things or hear things that others don’t. Is that what just happened?”
This response makes the client feel that experiencing hallucinations is acceptable and promotes an open, therapeutic relationship. Authenticity, empathy, understanding of illness and the person, non-stigmatization, and the ability to work as a team are essential characteristics that the nurse must have for the therapeutic relationship to be effective. It is crucial to work with insights into the disease, the importance of adherence, and the reduction of self-stigma. Establishing a therapeutic relationship with the person with schizophrenia is therefore a constant challenge that must accompany the various stages of the disease in cooperation with the family and the community.
Option B: Directing the client to look at the nurse wouldn’t address the obvious issue of the hallucination. As for the presence of hallucinations, the NIC defines the nursing diagnosis of Hallucination Control(6510) as the promotion of safety, comfort, and the hallucinating patient’s orientation towards reality.2 Auditory hallucinations are the most frequent, so the nurse must observe certain signs, such as taking a listening posture, unmotivated laughter, talking to oneself, and blocks in thinking, lack of attention, and distraction. In the presence of these signs, the nurse should avoid touching the patient without warning, as the touch may be understood as a threat.
Option C: It is important that the patient understands that the voices are unreal and are part of the disease, and distraction techniques can be used to direct the patient towards reality. Listening to music or watching television may be a good technique to distract the patient from the attention given to auditory hallucinations. These interventions are intended to establish a relationship of empathy and trust with the patient, causing the patient to begin to be critical towards the disease so that new intervention strategies can be implemented.
Option D: Confrontational approaches are likely to elicit an uninformative or negative response. Nurses must display an attitude of acceptance to help the patient share the content of the hallucination. This sharing is important to avoid unwanted reactions towards the self or others, if command hallucinations are present. The hallucination should not be reinforced, and the word “voices” should be used to refer to it, avoiding the word “they” which may indicate validation. It is also essential to make the patient realize that the nurse does not share the perception by saying, “I know the voices for you are real, but I do not hear any voices.”