2Therapeutic Relationship One of the most important skills a nurse can developCrucial to success of interventions with clients requiring psychiatric care
3Components of Therapeutic Relationship TrustBehaviors such as caring, interest, understanding, consistency, honesty, promise keeping, listening (Box 5.1)Congruence is essentialGenuine interestSelf-comfort, self-awareness of strengths and limitations, clear focus
4Components of Therapeutic Relationship (cont’d) EmpathyPutting oneself in client’s shoesClient 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)
5Self-Awareness Know self Values (sense of right and wrong, code of conduct for living)Values clarificationChoosingPrizingActingBeliefsAttitudes (Box 5.2 and Box 5.3)
6QuestionTell whether the following statement is true or false:A nurse displays empathy by showing feelings of concern and compassion.
7Empathy is putting one’s self into the client’s shoes. AnswerFalseEmpathy is putting one’s self into the client’s shoes.Sympathy is showing feelings of concern and compassion.
8Therapeutic Use of Self Use of aspects of personality, experience, values, feelings, intelligence, needs, coping skills, perceptions to establish relationships beneficial to clientsConcept developed by H. Peplau
9Therapeutic Use of Self (cont’d) Johari window: tool to learn about oneself4 quadrants: open/public self; blind/unaware self; hidden/private self; unknownGoal: move qualities from quadrants 2, 3, 4 into quadrant 1
11Ways of observing, understanding client interactions Patterns of KnowingWays of observing, understanding client interactionsFour 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)
12Patterns of Knowing (cont’d) Fifth pattern (Munhall, 1993): unknowingNurse admits lack of knowledge of client or understanding of client’s subjective world
13Types of Relationships SocialPurpose of friendship, socialization, companionship, or task accomplishmentSuperficial communication; shifting roles; outcomes rarely assessedIntimateEmotional commitment of two personsIndividual needs met; assistance with helping each other meet needs
14Types of Relationships (cont’d) TherapeuticFocus on needs, experiences, feelings, ideas of client onlyUse of communication skills, personal strengths, understanding of human behavior by nurseJoint agreement on areas to work on; outcome evaluation
15QuestionTell whether the following statement is true or false:A social relationship involves superficial communication for the purposes of friendship or task accomplishment.
16AnswerTrueA social relationship occurs for friendship, socialization, companionship or task achievement. It involves superficial communication with shifting roles.
17Establishing a Therapeutic Relationship Peplau’s model of three phasesOrientationWorkingTermination (Table 5.3)Overlapping, interlocking of phases
18Establishing a Therapeutic Relationship: Orientation Phase Meeting nurse, clientEstablishment of rolesDiscussion of purposes, parameters of future meetingsClarification of expectationsIdentification of client’s problemsNurse-client contracts/confidentiality, duty to warn/self-disclosure
19Establishing the Therapeutic Relationship: Working Phase Problem identification: issues or concerns identified by client; examination of client’s feelings and responsesExploitation: examination of feelings and responses; development of better coping skills, more positive self-image, behavior change, independencePossible transference/countertransference
20Establishing the Therapeutic Relationship: Termination Phase Begins when client’s problems are resolvedEnds when relationship is endedDeals with feelings of anger or abandonment that may occur; client may feel termination as impending loss
21Behaviors Diminishing Therapeutic Relationships Inappropriate boundaries (relationship becomes social or intimate)Feelings of sympathy, encouraging client dependencyNonacceptance of client, avoidance (Box 5.4)
22QuestionDuring the working phase of a nurse-client relationship, which of the following would occur?Expectations are clarifiedNurse-client contracts are establishedFeelings of loss are addressedClient feelings are examined
23Client’s feelings are examined AnswerClient’s feelings are examinedDuring 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.
24Therapeutic 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)
25Self-Awareness Issues Nurse’s self-awareness: crucial to developing therapeutic relationshipsHelpful activities: values clarification, journaling, group discussions, readingDevelopment of self-awareness: continual, ongoing process