1. Chapter 5: Therapeutic Relationships

2. Therapeutic Relationship
One of the most important skills a nurse can develop
Crucial to success of interventions with clients requiring psychiatric care

3. Components of Therapeutic Relationship
Trust
Behaviors such as caring, interest, understanding, consistency, honesty, promise keeping, listening (Box 5.1)
Congruence is essential
Genuine interest
Self-comfort, self-awareness of strengths and limitations, clear focus

4. Components of Therapeutic Relationship (cont’d)
Empathy
Putting oneself in client’s shoes
Client and nurse giving “gift of self”
Different from sympathy (feelings of concern or compassion; focus shifting to nurse’s feelings)
Acceptance (no judgments; set boundaries)
Positive regard (unconditional nonjudgmental attitude)

5. Self-Awareness Know self
Values (sense of right and wrong, code of conduct for living)
Values clarification
Choosing
Prizing
Acting
Beliefs
Attitudes (Box 5.2 and Box 5.3)

6. Question
Tell whether the following statement is true or false:
A nurse displays empathy by showing feelings of concern and compassion.

7. Empathy is putting one’s self into the client’s shoes.
Answer
False
Empathy is putting one’s self into the client’s shoes.
Sympathy is showing feelings of concern and compassion.

8. Therapeutic Use of Self
Use of aspects of personality, experience, values, feelings, intelligence, needs, coping skills, perceptions to establish relationships beneficial to clients
Concept developed by H. Peplau

9. Therapeutic Use of Self (cont’d)
Johari window: tool to learn about oneself
4 quadrants: open/public self; blind/unaware self; hidden/private self; unknown
Goal: move qualities from quadrants 2, 3, 4 into quadrant 1

10. Therapeutic Use of Self (cont’d)

11. Ways of observing, understanding client interactions
Patterns of Knowing
Ways of observing, understanding client interactions
Four patterns (Carper, 1978; Table 5.1)
Empirical (derived from nursing science)
Personal (from life experiences)
Ethical (from moral nursing knowledge)
Aesthetic (from art of nursing)

12. Patterns of Knowing (cont’d)
Fifth pattern (Munhall, 1993): unknowing
Nurse admits lack of knowledge of client or understanding of client’s subjective world

13. Types of Relationships
Social
Purpose of friendship, socialization, companionship, or task accomplishment
Superficial communication; shifting roles; outcomes rarely assessed
Intimate
Emotional commitment of two persons
Individual needs met; assistance with helping each other meet needs

14. Types of Relationships (cont’d)
Therapeutic
Focus on needs, experiences, feelings, ideas of client only
Use of communication skills, personal strengths, understanding of human behavior by nurse
Joint agreement on areas to work on; outcome evaluation

15. Question
Tell whether the following statement is true or false:
A social relationship involves superficial communication for the purposes of friendship or task accomplishment.

16. Answer
True
A social relationship occurs for friendship, socialization, companionship or task achievement. It involves superficial communication with shifting roles.

17. Establishing a Therapeutic Relationship
Peplau’s model of three phases
Orientation
Working
Termination (Table 5.3)
Overlapping, interlocking of phases

18. Establishing a Therapeutic Relationship: Orientation Phase
Meeting nurse, client
Establishment of roles
Discussion of purposes, parameters of future meetings
Clarification of expectations
Identification of client’s problems
Nurse-client contracts/confidentiality, duty to warn/self-disclosure

19. Establishing the Therapeutic Relationship: Working Phase
Problem identification: issues or concerns identified by client; examination of client’s feelings and responses
Exploitation: examination of feelings and responses; development of better coping skills, more positive self-image, behavior change, independence
Possible transference/countertransference

20. Establishing the Therapeutic Relationship: Termination Phase
Begins when client’s problems are resolved
Ends when relationship is ended
Deals with feelings of anger or abandonment that may occur; client may feel termination as impending loss

21. Behaviors Diminishing Therapeutic Relationships
Inappropriate boundaries (relationship becomes social or intimate)
Feelings of sympathy, encouraging client dependency
Nonacceptance of client, avoidance (Box 5.4)

22. Question
During the working phase of a nurse-client relationship, which of the following would occur?
Expectations are clarified
Nurse-client contracts are established
Feelings of loss are addressed
Client feelings are examined

23. Client’s feelings are examined
Answer
Client’s feelings are examined
During the working phase, the client identifies issues or concerns and his or her feelings and responses are examined.
Expectations are clarified and contracts are established during the orientation phase. Feelings of loss are addressed during the termination phase.

24. Therapeutic Roles of the Nurse in a Relationship
Teacher (coping, problem solving, medication regimen, community resources)
Caregiver (therapeutic relationship, physical care)
Advocate (ensuring privacy and dignity, informed consent, access to services, safety from abuse and exploitation)
Parent surrogate (Box 5.5)

25. Self-Awareness Issues
Nurse’s self-awareness: crucial to developing therapeutic relationships
Helpful activities: values clarification, journaling, group discussions, reading
Development of self-awareness: continual, ongoing process